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Dugdale CM, Zachary KC, McEvoy DS, Branda JA, Courtney A, Craig R, Doms A, Germaine L, Green CV, Gulbas E, Hooper DC, Hurtado RM, Hyle EP, Jerry MS, Lazarus JE, Paras M, Turbett SE, Shenoy ES. Second Time's the Charm? Assessing the Sensitivity and Yield of Inpatient Diagnostic Algorithms for Pulmonary Tuberculosis in a Low-Prevalence Setting. Open Forum Infect Dis 2024; 11:ofae253. [PMID: 38872849 PMCID: PMC11170497 DOI: 10.1093/ofid/ofae253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/30/2024] [Indexed: 06/15/2024] Open
Abstract
Background For persons with suspected pulmonary tuberculosis, the guidelines of the Centers for Disease Control and Prevention recommend collecting 3 respiratory specimens 8 to 24 hours apart for acid-fast bacilli (AFB) smear and culture, in addition to 1 nucleic acid amplification test (NAAT). However, data supporting this approach are limited. Our objective was to estimate the performance of 1, 2, or 3 AFB smears with or without NAATs to detect pulmonary tuberculosis in a low-prevalence setting. Methods We conducted a retrospective study of hospitalized persons at 8 Massachusetts acute care facilities who underwent mycobacterial culture on 1 or more respiratory specimens between July 2016 and December 2022. We evaluated percentage positivity and yield on serial AFB smears and NAATs among people with growth of Mycobacterium tuberculosis on mycobacterial cultures. Results Among 104 participants with culture-confirmed pulmonary tuberculosis, the first AFB smear was positive in 41 cases (39%). A second AFB smear was positive in 11 (22%) of the 49 cases in which it was performed. No third AFB smears were positive following 2 initial negative smears. Of 52 smear-negative cases, 36 had a NAAT performed, leading to 23 additional diagnoses. Overall sensitivity to detect tuberculosis prior to culture positivity was higher in any strategy involving 1 or 2 NAATs (74%-79%), even without AFB smears, as compared with 3 smears alone (60%). Conclusions Tuberculosis diagnostic testing with 2 AFB smears offered the same yield as 3 AFB smears while potentially reducing laboratory burden and duration of airborne infection isolation. Use of 1 or 2 NAATs increased sensitivity to detect culture-positive pulmonary tuberculosis when added to AFB smear-based diagnostic testing alone.
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Affiliation(s)
- Caitlin M Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kimon C Zachary
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Dustin S McEvoy
- Clinical Informatics, Mass General Brigham, Boston, Massachusetts, USA
| | - John A Branda
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amy Courtney
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Rebecca Craig
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Alexandra Doms
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lindsay Germaine
- Clinical Informatics, Mass General Brigham, Boston, Massachusetts, USA
| | - Chloe V Green
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Eren Gulbas
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David C Hooper
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Rocio M Hurtado
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Global Health Committee, Boston, Massachusetts, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle S Jerry
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
| | - Jacob E Lazarus
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Molly Paras
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah E Turbett
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erica S Shenoy
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infection Control, Massachusetts General Hospital and Mass General Brigham, Boston, Massachusetts, USA
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2
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Chun JY, Jeong SJ, Kim S, Choi S, Lee JH, Chung HS, Park S, Lee H, Kim HY, Hwangbo B, Choi YJ. Performance of the galactomannan test for the diagnosis of invasive pulmonary aspergillosis using non-invasive proximal airway samples. J Infect 2024; 88:106159. [PMID: 38641139 DOI: 10.1016/j.jinf.2024.106159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To diagnose invasive pulmonary aspergillosis (IPA), galactomannan (GM) detection in serum or bronchoalveolar lavage fluid (BALF) is widely used. However, the utility of proximal airway GM test (from induced sputum or tracheal aspirate) has not been well elucidated. METHODS In this retrospective cohort study, we evaluated the diagnostic performance of proximal airway GM in diagnosis of IPA including COVID-19 associated pulmonary aspergillosis (CAPA). Between January 2022 and January 2023, patients who had been tested for GM with clinical suspicion or for surveillance from any specimen (serum, induced sputum, tracheal aspirate, and BALF) were screened. IPA was diagnosed using EORTC/MSGERC criteria, and CAPA was diagnosed following the 2020 ECMM/ISHAM consensus criteria. RESULTS Of 624 patients with GM results, 70 met the criteria for proven/probable IPA and 427 had no IPA. The others included possible IPA and chronic form of aspergillosis. The sensitivities and specificities of serum, proximal airway, and BALF GM for proven/probable IPA versus no IPA were 78.9% and 70.6%, 93.1% and 78.7%, and 78.6% and 91.0%, respectively. Areas under the receiver operating characteristic curve (AUCs) were 0.742 for serum GM, 0.935 for proximal airway GM, and 0.849 for BALF GM (serum GM vs proximal airway GM, p = 0.014; proximal airway GM vs BALF GM, p = 0.334; serum GM vs BALF GM, p = 0.286). CONCLUSION This study demonstrates that the performance of GM test from non-invasive proximal airway samples is comparable or even better than those from serum and distal airway sample (BALF).
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Affiliation(s)
- June Young Chun
- Division of Infectious Disease, Department of Internal Medicine, National Cancer Center, Goyang, South Korea.
| | - Sahng-Joon Jeong
- Department of Internal Medicine, National Cancer Center, Goyang, South Korea
| | - Sinae Kim
- Biostatics Collaboration Team, Research Core Center, National Cancer Center, Goyang, South Korea
| | - Soyoung Choi
- Department of Agricultural Biotechnology, Seoul National University, Seoul, South Korea
| | - Jong Hyuk Lee
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea; College of Medicine, Seoul National University, Seoul, South Korea
| | - Hyun Sung Chung
- Division of Pulmonology, Department of Internal Medicine, National Cancer Center, Goyang, South Korea
| | - Seungman Park
- Department of Laboratory Medicine, National Cancer Center, Goyang, South Korea
| | - Hyewon Lee
- Division of Hemato-oncology, Department of Internal Medicine, National Cancer Center, Goyang, South Korea
| | - Hyae Young Kim
- Department of Radiology, National Cancer Center, Goyang, South Korea
| | - Bin Hwangbo
- Division of Pulmonology, Department of Internal Medicine, National Cancer Center, Goyang, South Korea
| | - Young Ju Choi
- Division of Infectious Disease, Department of Internal Medicine, National Cancer Center, Goyang, South Korea
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Freund O, Hadad Y, Lagziel T, Friedman Regev I, Kleinhendler E, Unterman A, Bar-Shai A, Perluk TM. The Added Value of Bronchoalveolar Lavage for Pulmonary Tuberculosis Diagnosis in High-Risk Hospitalized Patients with Negative Sputum Samples. Adv Respir Med 2023; 92:15-24. [PMID: 38392033 PMCID: PMC10885945 DOI: 10.3390/arm92010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/30/2023] [Accepted: 12/20/2023] [Indexed: 02/24/2024]
Abstract
Hospitalized patients with a high suspicion of pulmonary tuberculosis (HS-PTB) are isolated until a definite diagnosis can be determined. If doubt remains after negative sputum samples, bronchoscopy with bronchoalveolar lavage (BAL) is often sought. Still, evidence of the added value of BAL in this patient population is scarce. To address this issue, we included consecutive HS-PTB patients with negative sputum samples who underwent BAL between 2017 and 2018. Chest X-rays (CXR) and CT scans were evaluated by a chest radiologist blind to the final diagnosis. Independent predictors for PTB were assessed by multivariate regression, using all positive PTB patients between 2017 and 2019 (by sputum or BAL) as a control group (n = 41). Overall, 42 HS-PTB patients were included (mean age 51 ± 9, 36% female). BAL was a viable diagnostic for PTB in three (7%) cases and for other clinically relevant pathogens in six (14%). Independent predictors for PTB were ≥2 sub-acute symptoms (adjusted OR 3.18, 95% CI 1.04-9.8), CXR upper-lobe consolidation (AOR 8.70, 95% CI 2.5-29), and centrilobular nodules in chest CT (AOR 3.96, 95% CI 1.20-13.0, p = 0.02). In conclusion, bronchoscopy with BAL in hospitalized patients with HS-PTB had a 7% added diagnostic value after negative sputum samples. Our findings highlight specific predictors for PTB diagnosis that could be used in future controlled studies to personalize the diagnostic evaluation.
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Affiliation(s)
- Ophir Freund
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Yitzhac Hadad
- Radiology Department, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel
| | - Tomer Lagziel
- Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Inbal Friedman Regev
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Eyal Kleinhendler
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Avraham Unterman
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Amir Bar-Shai
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
| | - Tal Moshe Perluk
- Institute of Pulmonary Medicine, Sourasky Medical Center, Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel; (I.F.R.); (A.B.-S.)
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Griffith DE, Aksamit TR. Diagnostic Criteria and the Decision to Treat Nontuberculous Mycobacterial Pulmonary Disease. Clin Chest Med 2023; 44:757-769. [PMID: 37890914 DOI: 10.1016/j.ccm.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
The diagnosis of nontuberculous mycobacterial (NTM) pulmonary disease is based on three criteria: patient's symptoms, radiographic findings, and microbiologic results. The microbiologic criterion is the most complicated because it requires more than one positive sputum acid-fast bacilli culture. Clinicians are challenged to apply the diagnostic criteria in the context of variable patient symptoms, NTM pathogenicity, and host susceptibility. The decision to treat NTM pulmonary disease entails assessment of the risks and benefits of therapy and the patient's wishes and ability to receive treatment.
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Affiliation(s)
- David E Griffith
- Department of Medicine, Division of Mycobacterial Disease and Pulmonary Infections, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
| | - Timothy R Aksamit
- Pulmonary Disease and Critical Care Medicine, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA
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5
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Khan MA, Rajendram R, Al-Harbi A, Al-Ghamdi M, Masuadi E, Obaidi M, Al-Jahdali H. The diagnostic yield and safety of sputum induction in suspected pulmonary tuberculosis: The experience of a single tertiary care center in Saudi Arabia. Int J Mycobacteriol 2021; 10:388-392. [PMID: 34916456 DOI: 10.4103/ijmy.ijmy_203_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Sputum smear microscopy examination and culture for tuberculosis (TB) remain a fundamental tool of diagnosis but may be negative up to 50% case of active pulmonary TB. Bronchoscopy to obtain sputum is invasive and not readily available. Alternative methods of obtaining sputum specimens are crucial in suspected pulmonary TB cases who are unable to expectorate. In this context, it may be beneficial to stimulate sputum production by administering a mist of hypertonic saline produced by ultrasonic nebulization. The aims of the study are to describe the experience of a tertiary center in Saudi Arabia with sputum induction (SI) for the investigation of patients suspected to have sputum scare TB. Methods A retrospective cohort study was performed. All patients suspected of sputum scare TB and investigated with SI were included. Standard descriptive statistics were used. Categorical data presented as frequency were compared using the Chi square test. Continuous data presented as mean ± standard deviation were compared using Student's t test. Sensitivity, specificity, and predictive values were calculated. Results Of 252 patients with suspected TB who underwent SI, 78 (31%) were ultimately diagnosed to have TB. Culture of induced sputum confirmed the diagnosis of TB in 44 (56.4%) of these patients. However, the diagnosis of TB would have been missed in 13.5% of the cohort if no further investigations were done. The incidence of complications was low. No patients required hospitalization or specialist intervention. Conclusions SI is safe well tolerated and inexpensive. It may reduce the need for bronchoscopy in patients with suspected sputum scare TB. However, around 20% of TB can be missed by SI unless further investigations are performed. Hence, patients suspected to have sputum scare TB in whom the risk of bronchoscopy is high, a clinical decision on the appropriateness of empirical therapy is often required.
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Affiliation(s)
- Mohammed Ayaz Khan
- College of Medicine, King Saud University for Health Sciences; King Abdullah International Medical Research Centre; Department of Medicine, Division of Pulmonary, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Rajkumar Rajendram
- College of Medicine, King Saud University for Health Sciences; King Abdullah International Medical Research Centre;Department of Medicine, Internal Medicine Division, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Abdullah Al-Harbi
- College of Medicine, King Saud University for Health Sciences; King Abdullah International Medical Research Centre; Department of Medicine, Division of Pulmonary, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Majed Al-Ghamdi
- College of Medicine, King Saud University for Health Sciences; King Abdullah International Medical Research Centre; Department of Medicine, Division of Pulmonary, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Emad Masuadi
- College of Medicine, King Saud University for Health Sciences; King Abdullah International Medical Research Centre; Department of Medicine, Internal Medicine Division, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Mostafa Obaidi
- College of Medicine, King Saud University for Health Sciences; King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Hamdan Al-Jahdali
- College of Medicine, King Saud University for Health Sciences; King Abdullah International Medical Research Centre; Department of Medicine, Division of Pulmonary, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
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Das J, Idh N, Sikkeland LIB, Paues J, Lerm M. DNA methylome-based validation of induced sputum as an effective protocol to study lung immunity: construction of a classifier of pulmonary cell types. Epigenetics 2021; 17:882-893. [PMID: 34482796 PMCID: PMC9423833 DOI: 10.1080/15592294.2021.1969499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Flow cytometry is a classical approach used to define cell types in peripheral blood. While DNA methylation signatures have been extensively employed in recent years as an alternative to flow cytometry to define cell populations in peripheral blood, this approach has not been tested in lung-derived samples. Here, we compared bronchoalveolar lavage with a more cost-effective and less invasive technique based on sputum induction and developed a DNA methylome-based algorithm that can be used to deconvolute the cell types in such samples. We analysed the DNA methylome profiles of alveolar macrophages and lymphocytes cells isolated from the pulmonary compartment. The cells were isolated using two different methods, sputum induction and bronchoalveolar lavage. A strong positive correlation between the DNA methylome profiles of cells obtained with the two isolation methods was found. We observed the best correlation of the DNA methylomes when both isolation methods captured cells from the lower parts of the lungs. We also identified unique patterns of CpG methylation in DNA obtained from the two cell populations, which can be used as a signature to discriminate between the alveolar macrophages and lymphocytes by means of open-source algorithms. We validated our findings with external data and obtained results consistent with the previous findings. Our analysis opens up a new possibility to identify different cell populations from lung samples and promotes sputum induction as a tool to study immune cell populations from the lung.
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Affiliation(s)
- Jyotirmoy Das
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences,Linköping University, Linköping, Sweden
| | - Nina Idh
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences,Linköping University, Linköping, Sweden
| | - Liv Ingunn Bjoner Sikkeland
- Department of Respiratory Medicine, Rikshospitalet, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jakob Paues
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences,Linköping University, Linköping, Sweden.,Division of Infectious Diseases, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Maria Lerm
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences,Linköping University, Linköping, Sweden
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Luo W, Lin Y, Li Z, Wang W, Shi Y. Comparison of sputum induction and bronchoscopy in diagnosis of sputum smear-negative pulmonary tuberculosis: a systemic review and meta-analysis. BMC Pulm Med 2020; 20:146. [PMID: 32450826 PMCID: PMC7249394 DOI: 10.1186/s12890-020-01192-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 05/19/2020] [Indexed: 11/13/2022] Open
Abstract
Background Pulmonary tuberculosis is one of the most common infectious diseases worldwide. Patients with suspected pulmonary tuberculosis with negative smear are recommended to undergo further tests including sputum induction and bronchoscopy. Our study is aimed to compare sputum induction and bronchoscopic specimens in the diagnosis of sputum smear-negative pulmonary tuberculosis. Method PubMed, Web of Science, Cochrane Library and Embase were searched for eligible studies. The pooled sensitivities (SEN), specificities (SPE), positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and 95% confidence intervals (CI) were constructed, and the areas under the curves (AUCs) were calculated. Results Five studies with a total number of 586 cases were included. For mycobacterial culture, the SEN and SPE of sputum induction were 0.72(95% CI, 0.66–0.77) and 1.00(95%CI, 0.99–1.000) respectively, whereas the SEN and SPE of bronchoscopy were 0.70(95%CI, 0.64–0.75) and 1.00(95%CI, 0.99–1.00) respectively. Sputum induction had a similar AUC (0.9564, SE = 0.0749) with bronchoscopy (0.8618, SE = 0.1652) (P = 0.602). For specimen of acid-fast bacilli smear, the SEN and SPE of sputum induction were 0.35(95% CI, 0.29–0.42) and 0.99(95% CI, 0.96–1.00) respectively, whereas the SEN and SPE of bronchoscopy were 0.38(95% CI, 0.32–0.45) and 0.99(95% CI, 0.96–1.00) respectively. There is no statistically significant difference in the AUC for sputum induction (0.6016) compared with bronchoscopy (0.8163) (P = 0.792). Conclusions For the diagnosis of sputum smear-negative pulmonary tuberculosis, the diagnosis yield of sputum induction and bronchoscopy is similar.
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Affiliation(s)
- Wen Luo
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xiamen University, Xiamen, 361001, China
| | - Yihua Lin
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xiamen University, Xiamen, 361001, China
| | - Zhibin Li
- Epidemiology Research Unit, the First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Wanyu Wang
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xiamen University, Xiamen, 361001, China
| | - Yonghong Shi
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xiamen University, Xiamen, 361001, China.
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Symes MJ, Probyn B, Daneshvar C, Telisinghe L. Diagnosing Pulmonary Tuberculosis in the Elderly. CURRENT GERIATRICS REPORTS 2020. [DOI: 10.1007/s13670-020-00319-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Mohiuddin QA, Parkes L, Gardam M. Switching from expectorated to induced sputum cultures for tuberculosis diagnosis reduces cost without increasing risk. Am J Infect Control 2019; 47:1022-1024. [PMID: 30795839 DOI: 10.1016/j.ajic.2019.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/12/2019] [Accepted: 01/13/2019] [Indexed: 11/28/2022]
Abstract
Active pulmonary tuberculosis testing with 3 expectorated sputa can increase isolation days and expenditures compared with 1 induced sputum. Six-month retrospective and prospective chart reviews were conducted, and a screening algorithm was phased into 2 hospital sites. With induced sputum testing, isolation decreased from 7 to 4 days (interquartile range, 4-3, P = .0135), and there was a cost savings of $7,275 per case, with no added harm.
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Affiliation(s)
- Qasim A Mohiuddin
- Infection Prevention and Control, University Health Network, Toronto, ON, Canada.
| | - Leighanne Parkes
- Division of Infectious Diseases and Department of Medicine, Jewish General Hospital, Montréal, QC, Canada; Infection Prevention and Control, CIUSSS du Centre-Ouest-de-l'Île-de-Montréal, Montréal, QC, Canada
| | - Michael Gardam
- Tuberculosis Clinic, Toronto Western Hospital, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
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Xu P, Tang P, Song H, Zhao J, Chen H, Xue J, Zhai Y, Pang Y, Wu M. The incremental value of bronchoalveolar lavage for the diagnosis of pulmonary tuberculosis in a high-burden urban setting. J Infect 2019; 79:24-29. [PMID: 31100361 DOI: 10.1016/j.jinf.2019.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/14/2019] [Accepted: 05/10/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We prospectively evaluated the use of bronchoalveolar lavage fluid (BALF) specimens to assess their added incremental value to pulmonary tuberculosis (TB) diagnostic strategies used currently in a high-burden urban setting in China. METHODS A prospective study was conducted of patients with presumptive pulmonary TB registered at the Fifth Hospital of Suzhou between March 2018 and July 2018. BALF samples from patients with initial Xpert-negative sputum results were tested to diagnose TB. RESULTS Of 440 participants, 316 (71.8%) were initially diagnosed with TB from sputum, including 245 (55.7%) definitive TB cases based on a positive culture and/or Xpert result(s) and 71 (16.1%) positive cases based on clinical diagnosis. Of 153 patients with initial positive cultures, a significantly higher proportion were confirmed as TB-positive using Xpert (94.1%) versus smear microscopy (45.8%, P < 0.01). Xpert testing of BALF from 182 Xpert-negative cases exhibited greater detection sensitivity (97.4%) than did smear microscopy (23.4%, P < 0.01). Meanwhile, 74.1% of TB patients initially diagnosed as TB-negative via smear microscopy were identified using Xpert testing of BALF at reduced diagnostic cost/patient (from USD 266.9 to 171.5). CONCLUSIONS BALF samples added incremental value to pulmonary TB diagnostic strategies for patients with Xpert-negative sputum. Xpert outperformed smear microscopy for tubercle bacilli detection in both sputum and BALF.
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Affiliation(s)
- Ping Xu
- Department of Clinical Laboratory, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, No. 10, Guangqian Road, Xiangcheng District, Suzhou 215000, China; The Key Laboratory of Infection and Immunity of Suzhou City, Suzhou, China
| | - Peijun Tang
- Department of Tuberculosis, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, Suzhou, China
| | - Huafeng Song
- Department of Clinical Laboratory, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, No. 10, Guangqian Road, Xiangcheng District, Suzhou 215000, China; The Key Laboratory of Infection and Immunity of Suzhou City, Suzhou, China
| | - Jing Zhao
- Department of Clinical Laboratory, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, No. 10, Guangqian Road, Xiangcheng District, Suzhou 215000, China; The Key Laboratory of Infection and Immunity of Suzhou City, Suzhou, China
| | - Hui Chen
- Department of Clinical Laboratory, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, No. 10, Guangqian Road, Xiangcheng District, Suzhou 215000, China; The Key Laboratory of Infection and Immunity of Suzhou City, Suzhou, China
| | - Jing Xue
- Department of Clinical Laboratory, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, No. 10, Guangqian Road, Xiangcheng District, Suzhou 215000, China; The Key Laboratory of Infection and Immunity of Suzhou City, Suzhou, China
| | - Yunxia Zhai
- Department of Clinical Laboratory, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, No. 10, Guangqian Road, Xiangcheng District, Suzhou 215000, China; The Key Laboratory of Infection and Immunity of Suzhou City, Suzhou, China
| | - Yu Pang
- Department of Clinical Laboratory, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, No. 10, Guangqian Road, Xiangcheng District, Suzhou 215000, China; National Clinical Laboratory on Tuberculosis, Beijing Chest Hospital affiliated to Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Research Institute, No 9, Beiguan Street, Tongzhou District, Beijing 101149, China.
| | - Meiying Wu
- Department of Clinical Laboratory, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, No. 10, Guangqian Road, Xiangcheng District, Suzhou 215000, China; The Key Laboratory of Infection and Immunity of Suzhou City, Suzhou, China; Department of Tuberculosis, The Fifth People's Hospital of Suzhou, Infectious Disease Hospital Affiliated to Soochow University, Suzhou, China.
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Abstract
Introduction Early diagnosis and treatment of pulmonary tuberculosis (PTB) remains fundamental in reducing transmissions and death. Sputum induction is recommended for the diagnosis of pulmonary tuberculosis (PTB) in patients who are unable to expectorate or smear negative. Objective The aim of this study was to evaluate the diagnostic accuracy of pooling two induced sputum specimens into one microbiological test over a single day for the diagnosis of PTB. Methods We prospectively enrolled consecutive hospitalized adults with suspected PTB from 2009–2016. Two induced sputum specimens were obtained on the same day and pooled together for AFB smear, culture and Xpert MTB/RIF testing. The final diagnosis of PTB was based on a positive culture from any respiratory specimen. All patients were followed up for 3 months. Results Of 420 patients, 86(20.5%) were diagnosed with PTB based on a positive respiratory culture. The sensitivity, specificity, positive and negative predictive values for pooled induced sputum were 98.8% (CI 93.7–100%), 100% (CI 98.9–100%) and 100% (94.6–100%) and 99.7% (CI 98.1–100%) respectively. Xpert MTB/RIF in pooled induced sputum was positive in 88.4% of the PTB patients. Conclusion In the diagnosis of PTB, testing two induced sputum specimens which were pooled together for one microbiological testing process may be comparable to repeat testing.
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Affiliation(s)
- Mei Ying Chew
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Corresponding author at: Division of Respiratory and Critical Care Medicine, National University Hospital, Level 10, Tower Block, National University Health System, 1E Kent Ridge Road, Singapore 119228, Singapore.
| | - Jeffrey Ng
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tow Keang Lim
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Bhowmik A, Herth FJ. Bronchoscopy and other invasive procedures for tuberculosis diagnosis. Tuberculosis (Edinb) 2018. [DOI: 10.1183/2312508x.10020518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Paiva VDS, Staub FL, Valentini DF, Barcellos RB, Schmid KB, Costa ERD, Rossetti MLR, Dalcin PDTR, Silva DR. Polymerase chain reaction test in induced sputum of patients with pulmonary tuberculosis. CLINICAL RESPIRATORY JOURNAL 2018; 12:1865-1871. [PMID: 29215188 DOI: 10.1111/crj.12749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 10/13/2017] [Accepted: 12/02/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Induced sputum (IS) is an alternative method of obtaining sputum, but IS smears are frequently negative. Culture is more time consuming in its results, and less useful to guide the diagnosis. Polymerase chain reaction (PCR) is the most common methodology for rapid diagnosis of tuberculosis (TB), and few studies evaluated its role in IS samples. OBJECTIVES The objective of this study is to determine the diagnostic yield of PCR for TB compared with culture in IS samples. MATERIALS AND METHODS Prospective study. Inpatients and outpatients of >18 years with respiratory symptoms suggestive of PTB were invited to participate. The subjects were interviewed using a standardized questionnaire, and collected IS. Three samples were obtained for AFB smear and culture. A fourth sample was obtained for PCR test. RESULTS A total of 116 IS samples were evaluated. The sensitivity, specificity, positive predictive value and negative predictive values of PCR were 95.2%, 48.4%, 29.0% and 97.9%, respectively. The area under the receiver operating characteristic curve was .72 for the PCR test (P < .0001). CONCLUSIONS Although the PCR specificity could be underestimated, if we consider PCR to be more sensitive than the culture method used, we believed that these PCR-positive tests mean false positives. The results of PCR should always be interpreted carefully in conjunction with clinical information.
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Affiliation(s)
- Verônica da Silva Paiva
- Programa de Pós-Graduação em Ciências Pneumológicas, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil
| | - Fernanda Luiza Staub
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Dirceu Felipe Valentini
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Regina Bones Barcellos
- Centro de Desenvolvimento Científico e Tecnológico (CDCT), Fundação Estadual de Produção e Pesquisa em Saúde (FEPPS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Karen Barros Schmid
- Centro de Desenvolvimento Científico e Tecnológico (CDCT), Fundação Estadual de Produção e Pesquisa em Saúde (FEPPS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Elis Regina Dalla Costa
- Centro de Desenvolvimento Científico e Tecnológico (CDCT), Fundação Estadual de Produção e Pesquisa em Saúde (FEPPS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Maria Lucia Rosa Rossetti
- Centro de Desenvolvimento Científico e Tecnológico (CDCT), Fundação Estadual de Produção e Pesquisa em Saúde (FEPPS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Paulo de Tarso Roth Dalcin
- Programa de Pós-Graduação em Ciências Pneumológicas, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil.,Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Denise Rossato Silva
- Programa de Pós-Graduação em Ciências Pneumológicas, UFRGS, Porto Alegre, Rio Grande do Sul, Brazil.,Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.,Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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14
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Nachiappan AC, Rahbar K, Shi X, Guy ES, Mortani Barbosa EJ, Shroff GS, Ocazionez D, Schlesinger AE, Katz SI, Hammer MM. Pulmonary Tuberculosis: Role of Radiology in Diagnosis and Management. Radiographics 2017; 37:52-72. [PMID: 28076011 DOI: 10.1148/rg.2017160032] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Tuberculosis is a public health problem worldwide, including in the United States-particularly among immunocompromised patients and other high-risk groups. Tuberculosis manifests in active and latent forms. Active disease can occur as primary tuberculosis, developing shortly after infection, or postprimary tuberculosis, developing after a long period of latent infection. Primary tuberculosis occurs most commonly in children and immunocompromised patients, who present with lymphadenopathy, pulmonary consolidation, and pleural effusion. Postprimary tuberculosis may manifest with cavities, consolidations, and centrilobular nodules. Miliary tuberculosis refers to hematogenously disseminated disease that is more commonly seen in immunocompromised patients, who present with miliary lung nodules and multiorgan involvement. The principal means of testing for active tuberculosis is sputum analysis, including smear, culture, and nucleic acid amplification testing. Imaging findings, particularly the presence of cavitation, can affect treatment decisions, such as the duration of therapy. Latent tuberculosis is an asymptomatic infection that can lead to postprimary tuberculosis in the future. Patients who are suspected of having latent tuberculosis may undergo targeted testing with a tuberculin skin test or interferon-γ release assay. Chest radiographs are used to stratify for risk and to assess for asymptomatic active disease. Sequelae of previous tuberculosis that is now inactive manifest characteristically as fibronodular opacities in the apical and upper lung zones. Stability of radiographic findings for 6 months distinguishes inactive from active disease. Nontuberculous mycobacterial disease can sometimes mimic the findings of active tuberculosis, and laboratory confirmation is required to make the distinction. Familiarity with the imaging, clinical, and laboratory features of tuberculosis is important for diagnosis and management. ©RSNA, 2017.
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Affiliation(s)
- Arun C Nachiappan
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
| | - Kasra Rahbar
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
| | - Xiao Shi
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
| | - Elizabeth S Guy
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
| | - Eduardo J Mortani Barbosa
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
| | - Girish S Shroff
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
| | - Daniel Ocazionez
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
| | - Alan E Schlesinger
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
| | - Sharyn I Katz
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
| | - Mark M Hammer
- From the Department of Radiology, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Suite 130, Philadelphia, PA 19104 (A.C.N., E.J.M.B., S.I.K., M.M.H.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (K.R.); Department of Radiology (X.S.) and Department of Medicine, Section of Pulmonary and Critical Care Medicine (E.S.G.), Baylor College of Medicine, Houston, Tex; Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (G.S.S.); Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Tex (D.O.); and Department of Radiology, Texas Children's Hospital, Houston, Tex (A.E.S.)
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15
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Şimşek A, Yapıcı İ, Babalık M, Şimşek Z, Kolsuz M. Bronchoscopic diagnostic procedures and microbiological examinations in proving endobronchial tuberculosis. J Bras Pneumol 2017; 42:191-5. [PMID: 27383932 PMCID: PMC5569611 DOI: 10.1590/s1806-37562015000000134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 03/14/2016] [Indexed: 02/05/2023] Open
Abstract
Objective: To determine the proportional distribution of endobronchial tuberculosis (EBTB) subtypes and to evaluate the types of bronchoscopic diagnostic procedures that can prove granulomatous inflammation. Methods: This was a retrospective study of 18 HIV-negative patients with biopsy-proven EBTB treated between 2010 and 2014. Results: The most common EBTB subtypes, as classified by the bronchoscopic features, were tumorous and granular (in 22.2% for both). Sputum smear microscopy was performed in 11 patients and was positive for AFB in 4 (36.3%). Sputum culture was also performed in 11 patients and was positive for Mycobacterium tuberculosis in 10 (90.9%). Smear microscopy of BAL fluid (BALF) was performed in 16 patients and was positive for AFB in 10 (62.5%). Culture of BALF was also performed in 16 patients and was positive for M. tuberculosis in 15 (93.7%). Culture of BALF was positive for M. tuberculosis in 93.7% of the 16 patients tested. Among the 18 patients with EBTB, granulomatous inflammation was proven by the following bronchoscopic diagnostic procedures: bronchial mucosal biopsy, in 8 (44.4%); bronchial brushing, in 7 (38.8%); fine-needle aspiration biopsy, in 2 (11.1%); and BAL, in 2 (11.1%). Bronchial anthracofibrosis was observed in 5 (27.7%) of the 18 cases evaluated. Conclusions: In our sample of EBTB patients, the most common subtypes were the tumorous and granular subtypes. We recommend that sputum samples and BALF samples be evaluated by smear microscopy for AFB and by culture for M. tuberculosis, which could increase the rates of early diagnosis of EBTB. We also recommend that bronchial brushing be employed together with other bronchoscopic diagnostic procedures in patients suspected of having EBTB.
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Affiliation(s)
- Abdullah Şimşek
- Department of Chest Diseases, Prof. Dr. Türkan Akyol Chest Diseases Hospital, Bursa, Turkey
| | - İlhami Yapıcı
- Department of Chest Diseases, Prof. Dr. Türkan Akyol Chest Diseases Hospital, Bursa, Turkey
| | - Mesiha Babalık
- Department of Chest Diseases, Prof. Dr. Türkan Akyol Chest Diseases Hospital, Bursa, Turkey
| | - Zekiye Şimşek
- Department of Radiology, Bursa Çekirge Public Hospital, Bursa, Turkey
| | - Mustafa Kolsuz
- Department of Chest Diseases, Prof. Dr. Türkan Akyol Chest Diseases Hospital, Bursa, Turkey
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16
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Nay MA, Barbier F. Tuberculose chez les patients de réanimation. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1268-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Ko Y, Shin JH, Lee HK, Lee YS, Lee SY, Park SY, Mo EK, Kim C, Park YB. Duration of Pulmonary Tuberculosis Infectiousness under Adequate Therapy, as Assessed Using Induced Sputum Samples. Tuberc Respir Dis (Seoul) 2016; 80:27-34. [PMID: 28119744 PMCID: PMC5256343 DOI: 10.4046/trd.2017.80.1.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/09/2016] [Accepted: 10/24/2016] [Indexed: 11/25/2022] Open
Abstract
Background A sputum culture is the most reliable indicator of the infectiousness of pulmonary tuberculosis (PTB); however, a spontaneous sputum specimen may not be suitable. The aim of this study was to evaluate the infectious period in patients with non–drug-resistant (DR) PTB receiving adequate standard chemotherapy, using induced sputum (IS) specimens. Methods We evaluated the duration of infectiousness of PTB using a retrospective cohort design. Results Among the 35 patients with PTB, 22 were smear-positive. The rates of IS culture positivity from baseline to the sixth week of anti-tuberculosis medication in the smear-positive PTB group were 100%, 100%, 91%, 73%, 36%, and 18%, respectively. For smear-positive PTB cases, the median time of conversion to culture negativity was 35.0 days (range, 28.0–42.0 days). In the smear-negative PTB group (n=13), the weekly rates of positive IS culture were 100%, 77%, 39%, 8%, 0%, and 0%, respectively, and the median time to conversion to culture-negative was 21.0 days (range, 17.5–28.0 days). Conclusion The infectiousness of PTB, under adequate therapy, may persist longer than previously reported, even in patients with non-DR PTB.
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Affiliation(s)
- Yousang Ko
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea.; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jeong Hwan Shin
- Department of Laboratory Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyun-Kyung Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Young Seok Lee
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Suh-Young Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - So Young Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Eun-Kyung Mo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Changhwan Kim
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Korea
| | - Yong Bum Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.; Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
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18
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Lewinsohn DM, Leonard MK, LoBue PA, Cohn DL, Daley CL, Desmond E, Keane J, Lewinsohn DA, Loeffler AM, Mazurek GH, O'Brien RJ, Pai M, Richeldi L, Salfinger M, Shinnick TM, Sterling TR, Warshauer DM, Woods GL. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis 2016; 64:e1-e33. [PMID: 27932390 DOI: 10.1093/cid/ciw694] [Citation(s) in RCA: 281] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/14/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Individuals infected with Mycobacterium tuberculosis (Mtb) may develop symptoms and signs of disease (tuberculosis disease) or may have no clinical evidence of disease (latent tuberculosis infection [LTBI]). Tuberculosis disease is a leading cause of infectious disease morbidity and mortality worldwide, yet many questions related to its diagnosis remain. METHODS A task force supported by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America searched, selected, and synthesized relevant evidence. The evidence was then used as the basis for recommendations about the diagnosis of tuberculosis disease and LTBI in adults and children. The recommendations were formulated, written, and graded using the Grading, Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS Twenty-three evidence-based recommendations about diagnostic testing for latent tuberculosis infection, pulmonary tuberculosis, and extrapulmonary tuberculosis are provided. Six of the recommendations are strong, whereas the remaining 17 are conditional. CONCLUSIONS These guidelines are not intended to impose a standard of care. They provide the basis for rational decisions in the diagnosis of tuberculosis in the context of the existing evidence. No guidelines can take into account all of the often compelling unique individual clinical circumstances.
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Affiliation(s)
| | | | - Philip A LoBue
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David L Cohn
- Denver Public Health Department, Denver, Colorado
| | - Charles L Daley
- National Jewish Health and the University of Colorado Denver, and
| | - Ed Desmond
- California Department of Public Health, Richmond
| | | | | | - Ann M Loeffler
- Francis J. Curry International TB Center, San Francisco, California
| | | | | | - Madhukar Pai
- McGill University and McGill International TB Centre, Montreal, Canada
| | | | | | | | - Timothy R Sterling
- Vanderbilt University School of Medicine, Vanderbilt Institute for Global Health, Nashville, Tennessee
| | | | - Gail L Woods
- University of Arkansas for Medical Sciences, Little Rock
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19
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Rao GN, Venu M, Rani NU, Sravani M. Induced sputum versus bronchial washings in the diagnosis of sputum negative pulmonary tuberculosis. J Family Med Prim Care 2016; 5:435-439. [PMID: 27843856 PMCID: PMC5084576 DOI: 10.4103/2249-4863.192336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: Tuberculosis (TB) is one of the most important public health problems worldwide. Detecting patients with active pulmonary TB (PT) is an important component of TB control programs. However, at times in patients even with a compatible clinical picture, sputum smears do not reveal acid-fast bacilli (AFB) and smear-negative PT remains a common problem. This study compares the results of induced sputum (IS) and bronchial washings (BWs) in detecting sputum negative PT. Materials and Methods: A prospective study conducted from June 2014 to June 2015, comprising 120 patients fulfilling study criteria. Patients with respiratory symptoms and chest roentgenogram suspicious of PT with no previous history of antiTB treatment (ATT) and two spontaneous sputum smear samples negative for AFB were included in the study. Patients with active hemoptysis and sputum positive were excluded from the study. Sputum induction was done using 5–10 ml of 3% hypertonic saline through ultrasonic nebulizer taking safety precautions. All the patients underwent fiberoptic bronchoscopy after 6 h fasting on the same day. About 20 ml of normal saline instilled into the suspected pathology area and washings were taken with gentle suction. The sample processing and fluorescent staining for AFB were done in a designated microscopy laboratory. Results: Of 120 smear-negative PT patients, IS smear examination detected AFB in 76 patients (63.3%) and AFB detected from BWs in 94 patients (78.5%). Smear positivity higher in cavitary and infiltrative lesions compared to consolidation and infrahilar pattern disease. Conclusions: Even though both IS and BWs procedures were valuable for the diagnosis of smear-negative TB, sputum induction with hypertonic saline should be the initial procedure of choice, which can be repeated twice/thrice in a day or 2 consecutive days. If the patient remains IS smear-negative and if the clinical probability of TB is high, starting ATT and closely monitoring patient and reserving bronchoscopy to those patients who do not improve and to exclude alternative diagnosis seems to be a practically useful approach.
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Affiliation(s)
- Gopathi Nageswar Rao
- Department of Pulmonology, Government Hospital for Chest and Communicable Diseases, Katuri Medical College, Guntur, Andhra Pradesh, India
| | - Mandava Venu
- Department of Pulmonology, Government Hospital for Chest and Communicable Diseases, Katuri Medical College, Guntur, Andhra Pradesh, India
| | - Namballa Usha Rani
- Department of Pulmonology, Government Hospital for Chest and Communicable Diseases, Katuri Medical College, Guntur, Andhra Pradesh, India
| | - Makala Sravani
- Department of Pulmonology, Government Hospital for Chest and Communicable Diseases, Katuri Medical College, Guntur, Andhra Pradesh, India
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20
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Keeratichananont W, Nilmoje T, Keeratichananont S, Rittatorn J. Diagnostic yield and safety of sputum induction with nebulized racemic salbutamol versus hypertonic saline in smear-negative pulmonary tuberculosis. Ther Adv Respir Dis 2015. [PMID: 26206666 DOI: 10.1177/1753465815594529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The aim of the study was to compare the diagnostic yield and safety profile of sputum induction (SI) with nebulized racemic salbutamol solution versus hypertonic saline in smear-negative pulmonary tuberculosis (TB). METHODS The prospective study was conducted at Songklanagarind Hospital, Thailand. Suspected smear-negative pulmonary TB cases were recruited and randomized to receive SI with either nebulized racemic salbutamol solution or 3% sodium chloride (NaCl) solution. Induced sputum was examined with the acid-fast bacilli (AFB) smear test and cultured for Mycobacterium tuberculosis. The efficacy and adverse events of SI were analyzed. RESULTS A total of 59 patients received SI with nebulized racemic salbutamol solution and 53 received 3% NaCl solution. There was no significant difference between the two groups in the average quantity of induced sputum (1.3 ± 0.1 versus 1.2 ± 0.2 ml, p = 0.5). The percentages of positive AFB smear and TB cultures in the salbutamol group were 15% and 22%, and 13% and 17% in the 3% NaCl group (p = 0.5), respectively. Racemic salbutamol solution could increase the TB diagnostic yield similarly to 3% NaCl, but incurred less chest tightness (5% versus 15%) and bronchospasm (0% versus 11.3%, p = 0.02) compared with 3% NaCl. CONCLUSIONS SI by nebulized racemic salbutamol solution offers equal benefits to 3% NaCl solution in increasing both sputum quantity and diagnostic yield in smear-negative patients suspected of having pulmonary TB. Nebulized racemic salbutamol does not produce bronchospasm and chest tightness occurs less frequently than with 3% NaCl. Therefore, SI with nebulized racemic salbutamol solution should be considered as a good alternative noninvasive diagnostic tool for the diagnosis of pulmonary TB when hypertonic saline is unavailable or contraindicated.
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Affiliation(s)
- Warangkana Keeratichananont
- Assistant Professor, Division of Respiratory and Respiratory Critical Care Medicine, Department of Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Thanapon Nilmoje
- Department of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand
| | | | - Jedsada Rittatorn
- Department of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand
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Fløe A, Hilberg O, Thomsen VØ, Lillebaek T, Wejse C. Shortening Isolation of Patients With Suspected Tuberculosis by Using Polymerase Chain Reaction Analysis: A Nationwide Cross-sectional Study. Clin Infect Dis 2015; 61:1365-73. [PMID: 26175524 DOI: 10.1093/cid/civ563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 07/02/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Isolation of patients suspected for pulmonary tuberculosis is guided by serial sputum smears. This can result in isolation for days for patients with noncontagious tuberculosis. To determine whether a single sample negative for Mycobacterium tuberculosis complex at polymerase chain reaction (PCR) can guide isolation. METHODS We retrospectively evaluated sputum samples analyzed for M. tuberculosis complex at the International Reference Laboratory of Mycobacteriology, Copenhagen, Denmark in 2002-2011. We selected culture-confirmed tuberculosis cases with ≥3 samples within 14 days before or after the initial culture-positive sample. We repeated the process for those with ≥2 samples within 28 days. The primary outcome was PCR-negative, smear-positive patients. RESULTS We included 53 533 sputum samples from 20 928 individuals; 1636 had culture-confirmed tuberculosis. Of these, 856 had ≥3 sputum samples analyzed within the 28 days, and 482 had ≥1 PCR result. Nine patients (2.5% of smear-positive patients) were smear positive/PCR negative; 8 of the 9 had a smear-positive result in only 1 of 3 samples, and 5 had a low smear grade. Of 722 patients with 2 samples, 7 (1.3% of smear-positive patients) were smear positive/PCR negative. Overall, none were smear positive for the sample that produced the negative PCR result. CONCLUSIONS Primary PCR identified >97% of serial smear-positive cases. The majority of the missed cases had low-grade smears. Nevertheless, the occurrence of smear-positive/PCR-negative cases underlines the importance of increasing the quantity and quality of samples. Moreover, it is important that samples analyzed with PCR are cultured, owing to higher-sensitivity drug susceptibility testing, differential diagnosis, and surveillance.
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Affiliation(s)
| | - Ole Hilberg
- Departments of Respiratory Diseases and Allergy
| | | | - Troels Lillebaek
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Christian Wejse
- Infectious Diseases, Aarhus University Hospital GloHAU Center for Global Health, Department of Public Health, Aarhus University
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Park JS. Efficacy of Induced Sputum for the Diagnosis of Pulmonary Tuberculosis in Adults Unable to Expectorate Sputum. Tuberc Respir Dis (Seoul) 2015; 78:203-9. [PMID: 26175773 PMCID: PMC4499587 DOI: 10.4046/trd.2015.78.3.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 01/20/2015] [Accepted: 03/09/2015] [Indexed: 11/27/2022] Open
Abstract
Background Induced sputum (IS) has been used to collect airway secretions in subjects who have inadequate sputum production. The aim of this study was to investigate the efficacy of IS for the diagnosis of pulmonary tuberculosis (PTB) in adults unable to expectorate sputum. Methods Medical records of 39 PTB patients who underwent IS due to absence of spontaneous sputum production between January 2011 and March 2014 at a tertiary hospital in South Korea were reviewed. Results of acid fast bacilli smear, Mycobacterium tuberculosis culture and polymerase chain reaction assay for M. tuberculosis (TB-PCR) of IS specimens from these patients were analyzed. Clinical and high-resolution computed tomography (HRCT) characteristics were also analyzed to find characteristics associated with IS culture positivity. Results Of the 39 IS specimens from PTB patients, 7 (17.9%) were smear positive and 31 (79.5%) were culture positive. Twenty-four IS specimens were tested for TB-PCR and 13 (54.2%) were positive on TB-PCR. Multivariate analysis showed that younger age (p=0.04) and presence of tree-in-bud appearance on HRCT (p=0.03) were independent predictors of IS culture positivity. Conclusion IS is useful for the diagnosis of PTB in adults unable to expectorate sputum. Younger age and tree-in-bud appearance on HRCT were associated with IS culture positivity in these patients.
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Affiliation(s)
- Jae Seuk Park
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
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Phillips BL, Mehra S, Ahsan MH, Selman M, Khader SA, Kaushal D. LAG3 expression in active Mycobacterium tuberculosis infections. THE AMERICAN JOURNAL OF PATHOLOGY 2014; 185:820-33. [PMID: 25549835 DOI: 10.1016/j.ajpath.2014.11.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 10/22/2014] [Accepted: 11/03/2014] [Indexed: 01/22/2023]
Abstract
Mycobacterium tuberculosis (MTB) is a highly successful pathogen because of its ability to persist in human lungs for long periods of time. MTB modulates several aspects of the host immune response. Lymphocyte-activation gene 3 (LAG3) is a protein with a high affinity for the CD4 receptor and is expressed mainly by regulatory T cells with immunomodulatory functions. To understand the function of LAG3 during MTB infection, a nonhuman primate model of tuberculosis, which recapitulates key aspects of natural human infection in rhesus macaques (Macaca mulatta), was used. We show that the expression of LAG3 is highly induced in the lungs and particularly in the granulomatous lesions of macaques experimentally infected with MTB. Furthermore, we show that LAG3 expression is not induced in the lungs and lung granulomas of animals exhibiting latent tuberculosis infection. However, simian immunodeficiency virus-induced reactivation of latent tuberculosis infection results in an increased expression of LAG3 in the lungs. This response is not observed in nonhuman primates infected with non-MTB bacterial pathogens, nor with simian immunodeficiency virus alone. Our data show that LAG3 was expressed primarily on CD4(+) T cells, presumably by regulatory T cells but also by natural killer cells. The expression of LAG3 coincides with high bacterial burdens and changes in the host type 1 helper T-cell response.
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Affiliation(s)
- Bonnie L Phillips
- Division of Bacteriology, Tulane National Primate Research Center, Covington, Louisiana; Biomedical Sciences Graduate Student Program, New Orleans, Louisiana; National Institute of Respiratory Diseases, Mexico City, Mexico
| | - Smriti Mehra
- Division of Microbiology, Tulane National Primate Research Center, Covington, Louisiana
| | - Muhammad H Ahsan
- Division of Bacteriology, Tulane National Primate Research Center, Covington, Louisiana; Training in Lung Molecular and Cell Pathobiology Program, New Orleans, Louisiana
| | - Moises Selman
- National Institute of Respiratory Diseases, Mexico City, Mexico
| | - Shabaana A Khader
- Department of Molecular Microbiology and Immunology, Washington University of St. Louis, St. Louis, Missouri
| | - Deepak Kaushal
- Division of Bacteriology, Tulane National Primate Research Center, Covington, Louisiana; Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, Louisiana.
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Seong GM, Lee J, Lee JH, Kim JH, Kim M. Usefulness of sputum induction with hypertonic saline in a real clinical practice for bacteriological yields of active pulmonary tuberculosis. Tuberc Respir Dis (Seoul) 2014; 76:163-8. [PMID: 24851129 PMCID: PMC4021263 DOI: 10.4046/trd.2014.76.4.163] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/07/2014] [Accepted: 02/19/2014] [Indexed: 11/24/2022] Open
Abstract
Background Mycobacterial identification in active pulmonary tuberculosis (APTB) is confirmative, even though successful rates using self-expectorated sputum are limited. Sputum specimens collected by hypertonic saline nebulization showed higher bacteriologic diagnostic sensitivities over those of self-expectoration, mostly studied in smear-negative or sputum-scarce patients. The efficacy of induced sputum was rarely assessed in real clinical settings. Methods A prospective randomized case-control study was performed in one hospital. The subjects highly suspicious of APTB were asked to provide 3 pairs of sputum specimens in 3 consecutive days. The first pairs of the specimens were obtained either by self-expectoration (ES) from the next day of the visit or sputum induction with 7% saline nebulization in clinic (SI), and the other specimens were collected in the same way. The samples were tested in microscopy, culture, and polymerase chain reaction (PCR). The outcomes of the bacteriological diagnosis were compared. Results Seventy six patients were assigned to either ES (38 subjects, median age of 51, 65.8% male) or SI (38 subjects, median age of 55, 52.6% male). APTB was clinically confirmed in 51 patients (70.8%), 27 in ES and 24 in SI. Among the APTB, more adequate specimens were collected from SI (41/65, 63.1%) than ES (34/80, 42.5%) (p=0.01). Bacteriological confirmation was achieved in 14 (58.3%) patients in SI, and 13 (48.1%) in ES (p=0.46). In the same-day bacteriological diagnosis with microscopy and PCR, there were positive results for 9 patients (37.5%) in SI and 7 patients (25.9%) in ES (p=0.37). Conclusion Sputum induction improves sputum specimen adequacy. It may be useful for the same-day bacteriological diagnosis with microscopic examination and PCR.
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Affiliation(s)
- Gil Myeong Seong
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jaechun Lee
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Hoo Lee
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jeong Hong Kim
- Department of Otorhinolaryngology, Jeju National University School of Medicine, Jeju, Korea
| | - Miok Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
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Hagan G, Nathani N. Clinical review: tuberculosis on the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:240. [PMID: 24093433 PMCID: PMC4056111 DOI: 10.1186/cc12760] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Rates of tuberculosis (TB) are increasing in most west European nations. Patients with TB can be admitted to an ICU for a variety of reasons, including respiratory failure, multiorgan failure and decreased consciousness associated with central nervous system disease. TB is a treatable disease but the mortality for patients admitted with TB to an ICU remains high. Management challenges exist in establishing a prompt diagnosis and administering effective treatment on the ICU with potentially poor gastric absorption and high rates of organ dysfunction and drug toxicity. In this review reasons for ICU admission, methods of achieving a confident diagnosis through direct and inferred methods, anti-tuberculosis treatment (including steroid and other adjuvant therapies) and specific management problems with particular relevance to the intensivist are discussed. The role of therapeutic drug monitoring, judicious use of alternative regimes in the context of toxicity or organ dysfunction and when to suspect paradoxical tuberculosis reactions are also covered. Diagnostic and therapeutic algorithms are proposed to guide ICU doctors in the management of this sometimes complicated disease.
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Biswas S, Das A, Sinha A, Das SK, Bairagya TD. The role of induced sputum in the diagnosis of pulmonary tuberculosis. Lung India 2013; 30:199-202. [PMID: 24049254 PMCID: PMC3775199 DOI: 10.4103/0970-2113.116259] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Microbiological confirmation of pulmonary tuberculosis (TB) is of paramount importance in the era of immunocompromised host and emergence of multi-drug resistance. OBJECTIVES To assess the value of sputum induction (SI) with hypertonic saline nebulization as a diagnostic tool in patients with suspected pulmonary TB who have no/inadequate sputum or have a sputum smear negative for acid fast bacillus (AFB). MATERIALS AND METHODS One hundred patients with clinical and radiological evidence of pulmonary TB with no/inadequate sputum or smear negative with spontaneous sputum were studied. Sputum was induced with 20 mL of 3% hypertonic saline solution delivered through ultrasonic nebulizer. The specimens were subjected to Ziehl Neelsen staining and were examined under oil immersion lens for the presence of AFB. The specimens were also subjected to mycobacterial culture in BACTEC 460 TB system. RESULTS Ninety five patients could produce adequate sputum after SI. Sputum from thirty two patients were found to be positive both in smear and culture while sputum from another three patients were smear negative, but culture positive. CONCLUSION SI is a safe, cheap and non-invasive procedure and provides significant yield in the diagnosis of pulmonary TB; thus, increasing the case detection rate of smear positive pulmonary TB.
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Affiliation(s)
- Saurabh Biswas
- Department of Pulmonary Medicine, North Bengal Medical College, Darjeeling, West Bengal, India
| | - Anirban Das
- Department of Pulmonary Medicine, Medical College, Kolkata, West Bengal, India
| | - Arijit Sinha
- Department of Pulmonary Medicine, Medicine ID and BG Hospital, Kolkata, West Bengal, India
| | - Sibes K. Das
- Department of Pulmonary Medicine, Medical College, Kolkata, West Bengal, India
| | - Tapan Das Bairagya
- Department of Pulmonary Medicine, North Bengal Medical College, Darjeeling, West Bengal, India
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Peter JG, Theron G, Singh N, Singh A, Dheda K. Sputum induction to aid diagnosis of smear-negative or sputum-scarce tuberculosis in adults in HIV-endemic settings. Eur Respir J 2013; 43:185-94. [PMID: 23520317 DOI: 10.1183/09031936.00198012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sputum induction can aid tuberculosis (TB) diagnosis, but adult data from HIV-endemic environments are limited, and it is unclear how performance varies depending on the clinical context (in-patient versus outpatient), HIV status and whether patients are smear-negative or sputum-scarce. 696 adults with suspected smear-negative or sputum-scarce TB from Cape Town (South Africa) were referred for routine sputum induction. Liquid culture for Mycobacterium tuberculosis served as the reference standard. 82% (573 out of 696) of patients provided a specimen ≥1 mL, 83% (231 out of 278) of which were of adequate quality. 15% (96 out of 652) of sputum induction specimens were culture-positive, and this yield was higher among inpatients versus outpatients (17% (71 out of 408) versus 10% (25 out of 244), p=0.01) and HIV-infected versus uninfected patients (17% (51 out of 294) versus 9% (16 out of 173), p=0.02), but similar for CD4 (>200 versus ≤200 cells·μL(-1)) and patient (smear-negative versus sputum-scarce) subcategories. Overall sensitivity (95% CI) of smear-microscopy was 49% (39-59%), higher among in-patients versus outpatients (55% (43-67%) versus 32% (14-50%), p=0.05), but unaffected by HIV co-infection, CD4 count or patient type. 29% (203 out of 696) of patients commenced anti-TB treatment and sputum induction offered microbiological confirmation and susceptibility testing in only 47% (96 out of 203). Under programmatic conditions in an HIV-endemic environment although the yield of culture was approximately two-fold higher amongst HIV-infected patients and inpatients, a fifth of all patients were unable to provide a specimen following sputum induction. Same-day microbiological diagnosis was only possible in ~50% of patients.
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Affiliation(s)
- Jonathan G Peter
- Division of Pulmonology and UCT Lung Institute, Dept of Medicine, University of Cape Town, Cape Town
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Jacomelli M, Silva PRAA, Rodrigues AJ, Demarzo SE, Seicento M, Figueiredo VR. Bronchoscopy for the diagnosis of pulmonary tuberculosis in patients with negative sputum smear microscopy results. J Bras Pneumol 2012; 38:167-73. [PMID: 22576423 DOI: 10.1590/s1806-37132012000200004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 01/01/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of bronchoscopy in patients with clinical or radiological suspicion of tuberculosis who were unable to produce sputum or with negative sputum smear microscopy results. METHODS A prospective cross-sectional study involving 286 patients under clinical or radiological suspicion of having pulmonary tuberculosis and submitted to bronchoscopy-BAL and transbronchial biopsy (TBB). The BAL specimens were submitted to direct testing and culture for AFB and fungi, whereas the TBB specimens were submitted to histopathological examination. RESULTS Of the 286 patients studied, 225 (79%) were diagnosed on the basis of bronchoscopic findings, as follows: pulmonary tuberculosis, in 127 (44%); nonspecific chronic inflammation, in 51 (18%); pneumocystis, fungal infections, or nocardiosis, in 20 (7%); bronchiolitis obliterans organizing pneumonia, alveolites, or pneumoconiosis, in 14 (5%); lung or metastatic neoplasms, in 7 (2%); and nontuberculous mycobacterium infections, in 6 (2%). For the diagnosis of tuberculosis, BAL showed a sensitivity and a specificity of 60% and 100%, respectively. Adding the TBB findings significantly increased this sensitivity (to 84%), as did adding the post-bronchoscopy sputum smear microscopy results (total sensitivity, 94%). Minor post-procedure complications occurred in 5.6% of the cases. CONCLUSIONS Bronchoscopy is a reliable method for the diagnosis of pulmonary tuberculosis, with low complication rates. The combination of TBB and BAL increases the sensitivity of the method and facilitates the differential diagnosis with other diseases.
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Affiliation(s)
- Márcia Jacomelli
- Serviço de Endoscopia Respiratória Divisão de Pneumologia Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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Alamo ST, Kunutsor S, Walley J, Thoulass J, Evans M, Muchuro S, Matovu A, Katabira E. Performance of the new WHO diagnostic algorithm for smear-negative pulmonary tuberculosis in HIV prevalent settings: a multisite study in Uganda. Trop Med Int Health 2012; 17:884-95. [PMID: 22575012 DOI: 10.1111/j.1365-3156.2012.03003.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the performance of the new WHO (2007) diagnostic algorithm for pulmonary tuberculosis (PTB) in high HIV prevalent settings (WHO07) to the WHO 2003 guidelines used by the Ugandan National Tuberculosis Program (UgWHO03). METHODS A prospective observational cohort design was used at Reach Out Mbuya Parish HIV/AIDS Initiative, an urban slum community-based AIDS Service Organisation (ASO) and Kayunga Rural District Government Hospital. Newly diagnosed and enrolled HIV-infected patients were assessed for PTB. Research staff interviewed patients and staff and observed operational constraints. RESULTS WHO07 reduced the time to diagnosis of smear-negative PTB with increased sensitivity compared with the UgWHO03 at both sites. Time to diagnosis of smear-negative PTB was significantly shorter at the urban ASO than at the rural ASO (12.4 vs. 28.5 days, P = 0.003). Diagnostic specificity and sensitivity [95% confidence intervals (CIs)] for smear-negative PTB were higher at the rural hospital compared with the urban ASO: [98% (93-100%) vs. 86% (77-92%), P = 0.001] and [95% (72-100%) vs. 90% (54-99%), P > 0.05], respectively. Common barriers to implementation of algorithms included failure by patients to attend follow-up appointments and poor adherence by healthcare workers to algorithms. CONCLUSION At both sites, WHO07 expedited diagnosis of smear-negative PTB with increased diagnostic accuracy compared with the UgWHO03. The WHO07 expedited diagnosis more at the urban ASO but with more diagnostic accuracy at the rural hospital. Barriers to implementation should be taken into account when operationalising these guidelines for TB diagnosis in resource-limited settings.
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Gonzalez-Angulo Y, Wiysonge CS, Geldenhuys H, Hanekom W, Mahomed H, Hussey G, Hatherill M. Sputum induction for the diagnosis of pulmonary tuberculosis: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2011; 31:1619-30. [PMID: 22095153 DOI: 10.1007/s10096-011-1485-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 10/31/2011] [Indexed: 10/15/2022]
Abstract
Sputum induction (SI) has been proposed as the optimal sample collection method for patients with paucibacillary tuberculosis (TB). Studies reporting the culture of Mycobacterium tuberculosis from SI were reviewed. A random-effects meta-analysis of diagnostic yield (numerator M. tuberculosis SI culture-positive cases; denominator all culture-positive cases) was conducted. Diagnostic yields (95% confidence intervals, CIs) were displayed as Forest plots. Heterogeneity was evaluated using Chi-squared and I-squared tests and meta-regression analysis. Ninety publications were screened, 28 full-text papers reviewed, and 17 analyzed. Collectively, n=627 SI culture-positive cases among n=975 culture-confirmed TB cases were reported. The diagnostic yield of SI ranged from 35 to 95%. The pooled diagnostic yield was 74% (CI 65-81%), with significant heterogeneity (p<0.0001, I2=86%). There were no statistically significant differences in the yield between sub-groups defined by human immunodeficiency virus (HIV) prevalence or age. Univariate analysis demonstrated that the use of fiberoptic bronchoscopy (FOB) as the comparator method was associated with a 22% reduction (CI 2-42%) in the diagnostic yield of SI. However, after adjustment for confounding, the meta-regression analysis showed that FOB usage (p=0.21) and saline concentration (p=0.31) were not independently associated with the diagnostic yield. SI will detect approximately three-quarters of M. tuberculosis culture-positive cases under study conditions. Significant heterogeneity in the diagnostic yield was not explained by HIV prevalence, age, or the use of FOB as the comparator method. The use of a particular nebulized saline concentration for SI cannot be recommended on the basis of this meta-regression analysis.
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Affiliation(s)
- Y Gonzalez-Angulo
- South African Tuberculosis Vaccine Initiative (SATVI), Wernher Beit Building N2.10, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
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Achkar JM, Lawn SD, Moosa MYS, Wright CA, Kasprowicz VO. Adjunctive tests for diagnosis of tuberculosis: serology, ELISPOT for site-specific lymphocytes, urinary lipoarabinomannan, string test, and fine needle aspiration. J Infect Dis 2011; 204 Suppl 4:S1130-41. [PMID: 21996695 PMCID: PMC3192548 DOI: 10.1093/infdis/jir450] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The diagnostic gold standard for active tuberculosis (TB) is the detection of Mycobacterium tuberculosis (MTB) by culture or molecular methods. However, despite its limited sensitivity, sputum smear microscopy is still the mainstay of TB diagnosis in resource-limited settings. Consequently, diagnosis of smear-negative pulmonary and extrapulmonary TB remains challenging in such settings. A number of novel or alternative techniques could provide adjunctive diagnostic use in the context of difficult-to-diagnose TB. These may be especially useful in certain patient groups such as persons infected with human immunodeficiency virus (HIV) and children, who are disproportionably affected by smear-negative and extrapulmonary disease and who are also most adversely affected by delays in TB diagnosis and treatment. We review a selection of these methods that are independent of nucleic acid amplification techniques and could largely be implemented in resource-limited settings in current or adapted versions. Specifically, we discuss the diagnostic use and potential of serologic tests based on detection of antibodies to MTB antigens; interferon gamma release assays using site-specific lymphocytes; detection of lipoarabinomannan, a glycolipid of MTB, in urine; the string test, a novel technique to retrieve lower respiratory tract samples; and fine needle aspiration biopsy of lymph nodes.
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Affiliation(s)
- Jacqueline M Achkar
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
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Validation in Uganda of the new WHO diagnostic algorithm for smear-negative pulmonary tuberculosis in HIV prevalent settings. J Acquir Immune Defic Syndr 2011; 57:e93-100. [PMID: 21637111 DOI: 10.1097/qai.0b013e3182243a8c] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We compared the effectiveness of the new WHO 2007 diagnostic algorithm for pulmonary tuberculosis (PTB) for HIV prevalent settings (WHO07) to the WHO 2003 guidelines used by the Ugandan National Tuberculosis Program (UgWHO03) and most other countries for the diagnosis of smear-negative PTB. METHODS A prospective observational cohort design was employed under routine operational conditions at a District Hospital in Uganda. Newly diagnosed patients with HIV and enrolled to the outpatient HIV clinic were assessed for possible PTB. The study was in 2 phases with evaluation of the UgWHO03 and WHO07 over the first and second phases, respectively. RESULTS One hundred forty-seven enrolled onto the UgWHO03 and 166 onto WHO07. There were significant reductions in the geometric mean days (11.0 vs. 21.2, P < 0.05) and number of health facility visits (1.7 vs. 2.8, P < 0.001) from presentation to diagnosis of all PTB for the WHO07 compared with the UgWHO03. For smear-negative PTB, the geometric mean days (28.5 vs. 34.1, P > 0.05) and number of health facility visits (2.5 vs. 2.6, P > 0.05) from presentation to diagnosis were nonsignificantly reduced. Diagnostic sensitivity (95% confidence intervals) for smear-negative PTB increased nonsignificantly from 63% (27% to 90%) to 95% (72% to 100%) for the WHO07, with specificity (95% confidence interval) remaining high at 99% (92% to 100%) and 98% (93% to 100%). CONCLUSIONS Implementing the new WHO07 is likely to reduce the number of days and increase sensitivity for diagnosis of smear-negative cases of PTB. We identified many barriers to implementing both guidelines in HIV prevalent resource-poor settings.
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Induced sputum for the diagnosis of pulmonary tuberculosis: Is it useful in clinical practice? Can Respir J 2011; 17:e81-4. [PMID: 20808978 DOI: 10.1155/2010/426185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Diagnosing pulmonary tuberculosis (PTB) is challenging in patients who are unable to spontaneously expectorate. Published evidence suggests that induced sputum (IS) is the least invasive and most cost-effective method of diagnosis, and should be used before fibre-optic bronchoscopy (FOB). METHODS The medical records of 337 adults treated for PTB in northern Alberta between 1997 and 2007 were reviewed to determine whether local practice patterns reflect the evidence. Microbiological data were collected from the Provincial Laboratory for Public Health. Demographic information was collected from the patients' charts. RESULTS A total of 8.5% (26 of 307) of PTB patients had IS collected, whereas 35.8% (110 of 307) underwent FOB. Among FOB patients, 56.4% (62 of 110) had no sputum sent before the procedure and 29% (18 of 62) of these patients were smear positive. Only five patients referred for FOB had IS sent previously. There were no demographic factors predictive of IS use, whereas being an inpatient at a teaching facility or having a nodule or mass on chest x-ray was predictive of FOB referral. Because so few IS samples were available, not all patients had spontaneously expectorated sputum, IS and FOB tests performed; thus, the calculated yields were not comparable with one another. CONCLUSIONS Despite published evidence recommending IS collection before FOB referral in suspected PTB patients, clinicians in our health region appeared to prefer early FOB over IS by a large margin. This practice pattern is less cost effective and exposes patients and health care workers to greater risk. Further research is needed to identify the reasons for the underuse of sputum induction.
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El Khéchine A, Drancourt M. Diagnosis of pulmonary tuberculosis in a microbiological laboratory. Med Mal Infect 2011; 41:509-17. [DOI: 10.1016/j.medmal.2011.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 04/08/2011] [Accepted: 07/22/2011] [Indexed: 02/05/2023]
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George PM, Mehta M, Dhariwal J, Singanayagam A, Raphael CE, Salmasi M, Connell DW, Molyneaux P, Wickremasinghe M, Jepson A, Kon OM. Post-bronchoscopy sputum: improving the diagnostic yield in smear negative pulmonary TB. Respir Med 2011; 105:1726-31. [PMID: 21840695 DOI: 10.1016/j.rmed.2011.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Revised: 07/21/2011] [Accepted: 07/23/2011] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Patients with suspected active Pulmonary Tuberculosis (PTB) who are Acid-Fast Bacilli (AFB) smear negative or non-productive of sputum may undergo bronchoalveolar lavage. However, post-bronchoscopy sputum (PBS) sampling is not routine. The aim of this study was to establish the potential diagnostic value of PBS sampling. METHODS A retrospective study of patients attending a London University hospital with microbiologically confirmed PTB between January 2004 and December 2010. Patients who were AFB smear negative or non-productive of sputum were eligible if sputum sampling was performed within 7 days of bronchoscopy. RESULTS Over the study period, 236 patients had microbiologically confirmed smear negative PTB of which 57 patients were eligible for the study. 15 patients (26.3%) were infected with HIV. 19 patients (33.3%) converted to AFB sputum smear positivity post-bronchoscopy and 5 patients (8.8%) were exclusively AFB sputum smear positive on PBS microscopy. Mycobacterium tuberculosis was cultured from the PBS of 43 patients (75.4%) and of these, 4 (7.0%) were exclusively PBS culture positive. CONCLUSION PBS analysis can provide a simple method of rapidly diagnosing pulmonary tuberculosis. In this cohort, M. tuberculosis culture yield was increased by 7% through PBS sampling. This study has important infection control implications with nearly one third of patients becoming more infectious after bronchoscopy.
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Affiliation(s)
- Peter M George
- Chest and Allergy Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, UK.
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Bronchoscopy in suspected pulmonary TB with negative induced-sputum smear and MTD(®) Gen-probe testing. Respir Med 2011; 105:1084-90. [PMID: 21420844 DOI: 10.1016/j.rmed.2011.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 02/02/2011] [Accepted: 03/03/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION In our institution, patients with suspected pulmonary TB undergo multiple induced-sputum sampling for microscopy, culture and nucleic acid amplification (NAA) with the MTD(®) Gen-probe assay. Those with negative induced-sputum results still suspected with TB are then referred for bronchoscopy. We sought to determine the diagnostic yield of bronchoscopy in these patients with negative initial induced-sputum results both via smear and NAA testing. METHODS We identified 30 consecutive cases of suspected pulmonary TB between 2001 and 2007, who had undergone a diagnostic bronchoscopy after negative results on induced-sputum smears and the MTD(®) Gen-probe on at least 2 samples. RESULTS The cohort (M = 20 & F = 10) had a median age of 37 (range 16-85 yrs); were predominantly foreign born (27/30); HIV-negative (29/30) individuals with strongly positive TST's (mean 18 + 5 mm). Induced-sputum cultures were negative for M-TB in all patients after a full 60-day incubation period. BAL was culture positive for M-TB in 3/30 cases (10%) with 2 strains being pan-sensitive and the third being INH resistant. BAL microscopy with acid-fast smear (n = 30) and BAL Gen-probe (n = 23) were negative in all cases. A third of the patients (9/27, 33%) with negative bronchoscopy results were treated for culture negative TB. Treatment for latent TB was initiated in 5/27 (18%) individuals whereas 13/27 (48%) received no further treatment. CONCLUSION Bronchoscopy provided diagnostic confirmation of pulmonary TB in 10% of subjects at least 2 negative induced-sputum samples by smear microscopy and NAA testing.
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Kalawat U, Sharma KK, Reddy PNR, Kumar AG. Study of bronchoalveolar lavage in clinically and radiologically suspected cases of pulmonary tuberculosis. Lung India 2010; 27:122-4. [PMID: 20931028 PMCID: PMC2946711 DOI: 10.4103/0970-2113.68307] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
CONTEXT About 30 to 50 % of pulmonary tuberculosis patients have sputum report negative for acid fast bacilli or present with no expectoration. A lot of research is going on to find methods to establish early and accurate diagnosis of pulmonary tuberculosis (PTB) as institutions of early treatment can have significant effects on morbidity and mortality of patients and also the development of MDR-TB. Samples other than sputum play an important role in the diagnosis of disease in such patients. AIMS To assess the significance of bronchoalveolar lavage samples and fiberoptic bronchoscopy (FOB) in the early diagnosis of occult sputum smear negative pulmonary tuberculosis. SETTINGS AND DESIGN Study was conducted in a tertiary care hospital. FOB was performed in patients with three consecutive sputum smear negative acid fast bacilli to obtain bronchoalveolar lavage (BAL) samples. Written informed consent was obtained from these patients. MATERIALS AND METHODS BAL samples were subjected to Z-N staining and culture on L-J slopes for acid fast bacilli. Sputum samples from the same patients were also cultured. RESULTS BAL samples were positive in 82.2% of sputum smear negative samples. Culture positivity of BAL samples was 90.9% as compared to sputum culture positivity which was 26.4%. Overall diagnosis could be established in 86.6% of patients with the help of fiber optic bronchoscopy. CONCLUSIONS BAL samples are very useful in early sputum smear negative pulmonary tuberculosis and FOB can play an important role in diagnosis of lower respiratory tract infections with minimal complications in hands of an expert.
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Affiliation(s)
- Usha Kalawat
- Department of Microbiology, Srivenkateswara Institute of Medical Sciences, Tirupati- 517 507, Andhra Pradesh, India
| | - Krishna K. Sharma
- Department of Microbiology, Srivenkateswara Institute of Medical Sciences, Tirupati- 517 507, Andhra Pradesh, India
| | - Prakash N. R. Reddy
- Department of Microbiology, Srivenkateswara Institute of Medical Sciences, Tirupati- 517 507, Andhra Pradesh, India
| | - A. Gururaj Kumar
- Department of Microbiology, Srivenkateswara Institute of Medical Sciences, Tirupati- 517 507, Andhra Pradesh, India
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Kherad O, Herrmann FR, Zellweger JP, Rochat T, Janssens JP. Clinical presentation, demographics and outcome of tuberculosis (TB) in a low incidence area: a 4-year study in Geneva, Switzerland. BMC Infect Dis 2009; 9:217. [PMID: 20043847 PMCID: PMC2807871 DOI: 10.1186/1471-2334-9-217] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Accepted: 12/31/2009] [Indexed: 11/16/2022] Open
Abstract
Background The incidence of tuberculosis (TB) in developed countries has decreased since the 1990s, reflecting worldwide efforts to identify and treat TB according to WHO recommendations. However TB remains an important public health problem in industrialized countries with a high proportion of cases occurring among subjects originating from high prevalence countries. The aim of this study was to describe clinical and social characteristics of patients with TB and their outcome in a low incidence area with a high immigration rate. Methods Four-year retrospective study based on a computerized database and subsequent review of medical records of all patients with TB followed at the outpatient section of the Division of Pulmonary Diseases, Geneva University Hospital, Switzerland. Results 252 patients (84% foreigners, 25% asylum seekers) aged 38 ± 19 yrs were studied (11% co-infected with HIV). TB was intrapulmonary (TBP) in 158 cases (63%), extrapulmonary (TBE) in 137 (54%), and both in 43 cases (17%). TBP was smear (S)+/culture (C)+ in 59%, S-/C+ in 37%, S-/C- in 4%. Smoking was significantly associated with cavitary disease. Time from onset of symptoms to diagnosis was 2.1 ± 3.1 months. Initially, 10% were asymptomatic; 35% had no general symptoms. Despite systematic sputum analysis (induced or spontaneous), TBP was confirmed only by bronchoscopy in 38 subjects (24% of TBP). Side effects requiring changes in treatment occurred in 38 cases (11%). Treatment was completed in 210 (83%) patients. In 42 cases, follow up was unsuccessful; causes were: failure (n = 2; 0.8%), defaulters (n = 8; 3%), transfer out (n = 28; 11%) and death (n = 4; 1.6%). Relapse rate was 0.24 per 100 patient-years. Considering S+ TBP only, success rate was 87%. Conclusion TB in our area is predominantly a disease of young foreign-born subjects. Smoking appears as a possible risk factor for cavitary TBP. Time to diagnosis remains long. Compliance to treatment is satisfactory. Success rate for S+ TBP is within WHO objectives.
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Affiliation(s)
- Omar Kherad
- Department of Internal Medicine; Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
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Garcia SB, Perin C, Silveira MMD, Vergani G, Menna-Barreto SS, Dalcin PDTR. Bacteriological analysis of induced sputum for the diagnosis of pulmonary tuberculosis in the clinical practice of a general tertiary hospital. J Bras Pneumol 2009; 35:1092-9. [PMID: 20011844 DOI: 10.1590/s1806-37132009001100006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 08/07/2009] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To determine the diagnostic sensitivity of bacteriological analyses in induced sputum (IS) for the diagnosis of pulmonary tuberculosis (TB) and to identify the clinical characteristics associated with the confirmed diagnosis, as well as to determine the diagnostic yield of bronchoscopy carried out when IS tests negative for AFB in smear microscopy. METHODS A retrospective, cross-sectional study of patients suspected of having active pulmonary TB and referred to our clinic for sputum induction. We consecutively reviewed the laboratory data of all patients submitted to sputum induction between June of 2003 and January of 2006, as well as their electronic medical records. In addition, the results of the bacteriological analysis of bronchoscopic specimens collected from the patients whose AFB tests were negative in IS were reviewed. RESULTS Of the 417 patients included in the study, 83 (19.9%) presented IS samples that tested positive for TB (smear microscopy or culture). In the logistic regression analysis, radiological findings of cavitation (OR = 3.8; 95% CI: 1.9-7.6) and of miliary infiltrate (OR = 3.7; 95% CI: 1.6-8.6) showed the strongest association with the diagnosis of pulmonary TB. In 134 patients, bronchoscopy was carried out after negative AFB results in IS and added 25 (64.1%) confirmed diagnoses of pulmonary TB. CONCLUSIONS In our clinical practice, the frequency of confirmed diagnosis of pulmonary TB using IS (19.9%) was lower than that previously reported in controlled trials. Cavitation and miliary infiltrate increase the diagnostic probability of pulmonary TB using IS. The use of bronchoscopy when IS tests negative for AFB significantly increases sensitivity in the diagnosis of pulmonary TB.
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Lim TK, Cherian J, Poh KL, Leong TY. The rapid diagnosis of smear‐negative pulmonary tuberculosis: A cost‐effectiveness analysis. Respirology 2008. [DOI: 10.1111/j.1440-1843.2000.00284.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - K. L. Poh
- Industrial and Systems Engineering, National University of Singapore, Singapore
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Hirsch J, Ware LB, Matthay MA. Pulmonary Proteomics. Clin Proteomics 2008. [DOI: 10.1002/9783527622153.ch21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Brown M, Varia H, Bassett P, Davidson RN, Wall R, Pasvol G. Prospective study of sputum induction, gastric washing, and bronchoalveolar lavage for the diagnosis of pulmonary tuberculosis in patients who are unable to expectorate. Clin Infect Dis 2007; 44:1415-20. [PMID: 17479935 DOI: 10.1086/516782] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 02/12/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Many adults with pulmonary tuberculosis are unable to expectorate. Gastric washing, sputum induction using nebulized hypertonic saline, and bronchoscopy with bronchoalveolar lavage have all been used to obtain specimens for diagnosis, but to our knowledge, the timing and volume of induced sputum have not been well studied, and these 3 methods have not been compared. METHODS The study recruited consecutive adult inpatients with chest radiography findings suggestive of tuberculosis who were unable to expectorate. Subjects provided 3 induced sputum samples for culture on day 1 and additional samples on days 2 and 3. In addition, gastric washing specimens were collected on days 1, 2, and 3. A proportion of subjects with negative smear results underwent bronchoalveolar lavage. RESULTS The study recruited 140 subjects. Among 107 subjects who provided 3 gastric washing specimens and at least 3 induced sputum specimens, 43% had cultures positive for Mycobacterium tuberculosis. Use of 3 induced sputum samples detected more cases than did use of 3 gastric washings (39% vs. 30%; P=.03). Among 79 subjects with culture results for all 5 induced sputum specimens, there was no difference in yield between samples obtained by induced sputum induction performed in a single day or that performed over 3 days (34% vs. 37%; P=.63). There was no association between sputum volume and positive culture results. No additional cases were diagnosed in the 21 patients who underwent bronchoscopy. CONCLUSIONS Use of 3 induced sputum samples was more sensitive than use of 3 gastric washings for diagnosis of tuberculosis in patients who could not expectorate spontaneously. Use of bronchoscopy with bronchoalveolar lavage did not increase diagnostic sensitivity. Samples could be collected in 1 day, allowing for faster diagnosis, faster initiation of treatment, and shorter hospital stay.
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Affiliation(s)
- Michael Brown
- Department of Infection and Tropical Medicine, Lister Unit, Northwick Park Hospital, Harrow, Middlesex, United Kingdom.
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Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, Holland SM, Horsburgh R, Huitt G, Iademarco MF, Iseman M, Olivier K, Ruoss S, von Reyn CF, Wallace RJ, Winthrop K. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007; 175:367-416. [PMID: 17277290 DOI: 10.1164/rccm.200604-571st] [Citation(s) in RCA: 4015] [Impact Index Per Article: 236.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Schoch OD, Rieder P, Tueller C, Altpeter E, Zellweger JP, Rieder HL, Krause M, Thurnheer R. Diagnostic yield of sputum, induced sputum, and bronchoscopy after radiologic tuberculosis screening. Am J Respir Crit Care Med 2006; 175:80-6. [PMID: 17053204 DOI: 10.1164/rccm.200608-1092oc] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE To assess feasibility and yield of diagnostic procedures after active case finding for tuberculosis with radiologic screening at the three main entry points for asylum seekers to Switzerland. METHOD Prospective multicenter study on the value of symptoms, spontaneous and induced sputum, and bronchoscopy for the confirmation of tuberculosis in radiologically selected cases. RESULTS Among 101 asylum seekers examined, spontaneous sputum was collected "on the spot" in 83 and yielded 7 (54%) of 13 smear-positive and 13 (39%) of 33 culture-positive cases. Morning sputum, collected in 84, yielded 8 (62%) and 16 (49%), and the two spontaneous sputa combined 9 (69%) and 20 (61%), respectively. Two additional induced sputa, collected in 91 persons, yielded no additional smear-positive, but yielded seven culture-positive cases (yield, 82%). Bronchoscopy, performed in 87 of 92 sputum smear-negative cases, yielded four additional smear-positive and six culture-positive cases. Culture confirmation was independently and significantly predicted by obtaining a specimen using bronchoscopy (adjusted odds ratio, 11.0; 95% confidence interval, 1.9-62) and a prior decision to treat (adjusted odds ratio, 3.0; confidence interval, 1.1-8.1). CONCLUSION Radiographic anomalies compatible with tuberculosis found during screening are a poor guide to initiation of treatment. Respiratory and systemic symptoms correlated weakly with culture confirmation of tuberculosis. All radiologically selected cases must be examined with on-the-spot and early-morning sputum, regardless of symptoms. If both specimens are smear negative, the yield is increased by bronchoscopy and, to a lesser extent, by two samples of induced sputum. The examination of any single specimen has a low yield of 36 to 63% and is insufficient to exclude active tuberculosis.
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Affiliation(s)
- Otto D Schoch
- Pneumology, Kantonsspital St. Gallen, CH-9007 St. Gallen, Switzerland.
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Wisnivesky JP, Serebrisky D, Moore C, Sacks HS, Iannuzzi MC, McGinn T. Validity of clinical prediction rules for isolating inpatients with suspected tuberculosis. A systematic review. J Gen Intern Med 2005; 20:947-52. [PMID: 16191144 PMCID: PMC1490232 DOI: 10.1111/j.1525-1497.2005.0185.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Declining rates of tuberculosis (TB) in the United States has resulted in a low prevalence of the disease among patients placed on respiratory isolation. The purpose of this study is to systematically review decision rules to predict the patient's risk for active pulmonary TB at the time of admission to the hospital. DATA SOURCES We searched MEDLINE (1975 to 2003) supplemented by reference tracking. We included studies that reported the sensitivity and specificity of clinical variables for predicting pulmonary TB, used Mycobacterium TB culture as the reference standard, and included at least 50 patients. REVIEW METHOD Two reviewers independently assessed study quality and abstracted data regarding the sensitivity and specificity of the prediction rules. RESULTS Nine studies met inclusion criteria. These studies included 2,194 participants. Most studies found that the presence of TB risk factors, chronic symptoms, positive tuberculin skin test (TST), fever, and upper lobe abnormalities on chest radiograph were associated with TB. Positive TST and a chest radiograph consistent with TB were the predictors showing the strongest association with TB (odds ratio: 5.7 to 13.2 and 2.9 to 31.7, respectively). The sensitivity of the prediction rules for identifying patients with active pulmonary TB varied from 81% to 100%; specificity ranged from 19% to 84%. CONCLUSIONS Our analysis suggests that clinicians can use prediction rules to identify patients with very low risk of infection among those suspected for TB on admission to the hospital, and thus reduce isolation of patients without TB.
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Affiliation(s)
- Juan P Wisnivesky
- Division of General Internal Medicine, Mount Sinai Medical Center, New York, NY. USA.
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Saglam L, Akgun M, Aktas E. Usefulness of induced sputum and fibreoptic bronchoscopy specimens in the diagnosis of pulmonary tuberculosis. J Int Med Res 2005; 33:260-5. [PMID: 15790139 DOI: 10.1177/147323000503300215] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We investigated the diagnostic value of induced sputum (IS) and bronchial lavage (BL) specimens in patients with suspected pulmonary tuberculosis who had negative spontaneous sputum specimens or who were unable to produce sputum spontaneously. IS specimens and BL specimens obtained using flexible fibreoptic bronchoscopy from 55 patients were evaluated for the presence of acid-fast bacilli (AFB) and cultured for Mycobacterium tuberculosis. Positive results were found with IS smear in 23 patients, BL smear in 26 patients, and IS or BL culture in 42 patients. Culture of BL specimens had a higher sensitivity than IS or BL smears or culture of IS specimens. The highest sensitivity rate was obtained with a positive BL or IS culture (86%). For early diagnosis (a positive IS or BL smear), the sensitivity was 57%. IS has a higher sensitivity rate than spontaneous sputum for the detection of tuberculosis, and fibreoptic bronchoscopy is useful for the early diagnosis of tuberculosis when AFB are not detected in spontaneous or induced sputum specimens.
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Affiliation(s)
- L Saglam
- Department of Chest Diseases, Faculty of Medicine, Atatürk University, Erzurum, Turkey.
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Abstract
Diagnostic testing for tuberculosis has remained unchanged for nearly a century, but newer technologies hold the promise of a true revolution in tuberculosis diagnostics. New tests may well supplant the tuberculin skin test in diagnosing latent tuberculosis infection in much of the world. Tests such as the nucleic acid amplification assays allow more rapid and accurate diagnosing of pulmonary and extrapulmonary tuberculosis. The appropriate and affordable use of any of these tests depends on the setting in which they are employed.
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Affiliation(s)
- Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, 622 West 168th Street, PH 8 East, Room 101, New York, NY 10032, USA
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Caymmi ALS, Silveira MAS, Montal G, Lemos ACM. Papel da fibrobroncoscopia no diagnóstico de pacientes com suspeita de tuberculose pulmonar. J Bras Pneumol 2004. [DOI: 10.1590/s1806-37132004000100008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUÇÃO: A tuberculose pulmonar é uma doença infectocontagiosa de elevadas incidência e prevalência. O diagnóstico é feito de maneira rápida e segura através da baciloscopia do escarro. Entretanto, dos portadores de tuberculose pulmonar, 30% a 50% têm baciloscopia do escarro negativa ou não têm escarro, o que faz com que a fibrobroncoscopia adquira especial importância nesses casos. OBJETIVO: Avaliar a sensibilidade de espécimes colhidos, através da fibrobroncoscopia (lavado broncoalveolar e biópsia transbrônquica), para o diagnóstico de pacientes com suspeita de tuberculose pulmonar, sem confirmação diagnóstica através da baciloscopia do escarro. MÉTODO: Através da revisão dos livros de registro das fibrobroncoscopias realizadas no Hospital Universitário Professor Edgard Santos e no Hospital São Rafael, entre março de 1997 e março de 2001, foram identificados e incluídos no estudo os pacientes maiores de 18 anos, e encaminhados devido a suspeita de tuberculose com, no mínimo, três baciloscopias do escarro negativas. Foram coletados dados referentes a idade, sexo, alteração radiológica e alterações encontradas durante o exame endoscópico. RESULTADOS: Foram identificados 52 pacientes, com idade variando de 19 a 77 anos (mediana de 39), sendo 58% do sexo masculino e 37% atendidos pelo SUS. A apresentação radiológica predominante foi o infiltrado alveolar (80%). Tuberculose foi o diagnóstico final em 35 pacientes (1 com neoplasia associada), e a broncoscopia foi diagnóstica em 28 pacientes (80%). Outros diagnósticos obtidos pela broncoscopia foram: neoplasia, histoplasmose, alveolite crônica eosinofilica, pneumonia por Pneumocystis carinii e fibrose pulmonar. CONCLUSÃO: Os resultados deste estudo indicam a realização da fibrobroncoscopia em pacientes com suspeita de tuberculose não confirmada através da baciloscopia do escarro para determinação diagnóstica, não só desta doença, como de todas as que representam diagnósticos diferenciais.
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