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Dhanalakshmi M, Pandya M, Sruthi D, Jinuraj KR, Das K, Gadnayak A, Dave S, Andal NM. The artificial neural network selects saccharides from natural sources a promise for potential FimH inhibitor to prevent UTI infections. In Silico Pharmacol 2024; 12:37. [PMID: 38706885 PMCID: PMC11063016 DOI: 10.1007/s40203-024-00212-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/13/2024] [Indexed: 05/07/2024] Open
Abstract
The major challenge in the development of affordable medicines from natural sources is the unavailability of logical protocols to explain their mechanism of action in biological targets. FimH (Type 1 fimbrin with D-mannose specific adhesion property), a lectin on E. coli cell surface is a promising target to combat the urinary tract infection (UTI). The present study aimed at predicting the inhibitory capacity of saccharides on FimH. As mannosides are considered FimH inhibitors, the readily accessible saccharides from the PubChem collection were utilized. The artificial neural networks (ANN)-based machine learning algorithm Self-organizing map (SOM) has been successfully employed in predicting active molecules as they could discover relationships through self-organization for the ligand-based virtual screening. Docking was used for the structure-based virtual screening and molecular dynamic simulation for validation. The result revealed that the predicted molecules malonyl hexose and mannosyl glucosyl glycerate exhibit exactly similar binding interactions and better docking scores as that of the reference bioassay active, heptyl mannose. The pharmacokinetic profile matches that of the selected bioflavonoids (quercetin malonyl hexose, kaempferol malonyl hexose) and has better values than the control drug bioflavonoid, monoxerutin. Thus, these two molecules can effectively inhibit type 1 fimbrial adhesin, as antibiotics against E. coli and can be explored as a prophylactic against UTIs. Moreover, this investigation can pave the way to the exploration of the potential benefits of plant-based treatments. Graphical abstract Supplementary Information The online version contains supplementary material available at 10.1007/s40203-024-00212-5.
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Affiliation(s)
| | - Medha Pandya
- Department of Life Sciences, Maharaja Krishnakumarsinhji Bhavnagar University, Bhavnagar, Gujarat India
| | - Damodaran Sruthi
- Department of Biochemistry, Indian Institute of Science, Bengaluru, Karnataka India
| | - K. Rajappan Jinuraj
- Open Source Pharma Foundation, Manyatha Tech Park, MFAR Green Heart Building, Hebbal, Bengaluru, Karnataka India
| | - Kajari Das
- Department of Biotechnology, College of Basic Science and Humanities, Odisha University of Agriculture and Technology, Bhubaneswar, Odisha India
| | - Ayushman Gadnayak
- ICAR-Central Inland Fisheries Research Institute, Barrackpore, Kolkata India
| | - Sushma Dave
- Department of Chemistry, JIET, Jodhpur, Rajasthan India
| | - N. Muthulakshmi Andal
- Department of Chemistry, PSGR Krishnammal College for Women, Coimbatore, Tamil Nadu India
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Kanthawang T, Pattamapaspong N, Peh WCG, Hammami N, Bouaziz MC, Ladeb MF. Imaging of infra-thoracic tuberculosis. Br J Radiol 2024; 97:492-504. [PMID: 38288505 DOI: 10.1093/bjr/tqad051] [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: 08/03/2023] [Revised: 11/16/2023] [Accepted: 11/29/2023] [Indexed: 03/01/2024] Open
Abstract
Tuberculosis (TB) is a potentially curable disease that is a leading cause of death globally. While it typically affects the lungs, this disease may involve many extra-pulmonary sites, particularly in patients with risk factors. Extra-pulmonary TB often mimics a variety of different diseases, posing a diagnostic dilemma. Imaging aids in early diagnosis of TB, especially in patients with non-specific or atypical symptoms found at extra-pulmonary infra-thoracic locations. Imaging also helps guide appropriate laboratory investigation, monitor disease progress, and response to treatment. This review aims to highlight the imaging spectrum of TB affecting the infra-thoracic region, that is, gastrointestinal tract, abdominal lymph nodes, peritoneal cavity, intra-abdominal solid organs, and urogenital system.
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Affiliation(s)
- Thanat Kanthawang
- Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Nuttaya Pattamapaspong
- Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Wilfred C G Peh
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore 768828
| | - Nadia Hammami
- Department of Neuroradiology, National Institute of Neurology Mongi Ben Hamida, Tunis 1007, Tunisia
| | - Mouna Chelli Bouaziz
- Department of Radiology, Faculty of Medicine of Tunis, MT Kassab Institute of Orthopaedics, Tunis-El Manar University, Ksar Said, Tunis 2010, Tunisia
| | - Mohamed Fethi Ladeb
- Department of Radiology, Faculty of Medicine of Tunis, MT Kassab Institute of Orthopaedics, Tunis-El Manar University, Ksar Said, Tunis 2010, Tunisia
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Kalyesubula R, Wearne N, Kubo M, Hussey N, Naicker S. HIV and Associated TB: A Lethal Association for Kidney Health? Semin Nephrol 2023; 43:151470. [PMID: 38245391 DOI: 10.1016/j.semnephrol.2023.151470] [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: 01/22/2024]
Abstract
Human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading infectious causes of death globally. The combined brunt of these diseases is experienced mainly in low-income and lower-middle-income countries. HIV/TB have devastating effects on the kidneys, leading to accelerated decline of kidney function as well as mortality. Managing the triad of TB/HIV and kidney disease is challenging. We discuss the epidemiology of HIV/TB coinfection and the kidney and the key mechanisms of kidney disease including genetic susceptibility. The clinical presentation and pathology, as well as the challenges of diagnosing CKD in these patients, also are discussed. The strategies to prevent and manage HIV/TB-related kidney disease such as proper assessment, avoiding nephrotoxic regimens, drug dose adjustments, kidney function monitoring, avoidance of drug-drug interactions, and other interventions are explored. We also briefly discuss the complexities around HIV/TB patients on dialysis and kidney transplantation. HIV/TB coinfection presents an increased risk for kidney-related morbidity and mortality; patients with this triad need to be given special consideration for future research and management.
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Affiliation(s)
- Robert Kalyesubula
- Department of Physiology and Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Nicola Wearne
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Mary Kubo
- Department of Clinical Medicine and Therapeutics, East African Kidney Institute, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya.
| | - Nadia Hussey
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Saraladevi Naicker
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Kundasamy P, Kemp B, Kearns D, McCallum A, Nazir S, Lyon PC. A rare case of disseminated genitourinary tract tuberculosis complicated by emphysematous prostatitis and seminal vesicle abscess. BJR Case Rep 2023; 9:20220101. [PMID: 36873231 PMCID: PMC9976721 DOI: 10.1259/bjrcr.20220101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/13/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022] Open
Abstract
Urogenital tuberculosis (UGTB) can affect the entire urinary tract including the kidneys, ureters (strictures), urinary bladder, prostate in addition to involving reproductive tracts. In modern day practice, both ultrasound and cross-sectional imaging play an important role in the radiological diagnosis of UGTB. The sequalae of untreated UGTB is morbid and can lead to end-stage renal failure, infertility, and life-threatening systemic infection. UGTB is less commonly observed in developed countries and may mimic other pathologies including malignancy. Thus, it is important that radiologists consider the differential diagnosis early, particularly individuals with risk factors such as travel to endemic regions, to allow optimal treatment and ensure best prognostic outcomes. UGTB can typically be managed by Infectious Disease clinicians with multidrug chemotherapy. We have presented a case of microbiologically proven extrapulmonary tuberculosis (TB) predominantly involving the genitourinary tract. The response to TB agents and lack of evidence of co-infection with another organism, might suggest this as the first published case of emphysematous tuberculous prostatitis. Emphysematous prostatitis is indicative of a gas-forming infection of the prostate, and is associated with abscess formation in the vast majority of case and is an easily identified radiological feature on CT. It is not a well-recognised feature of Mycobacterium tuberculosis infection and thus microbiological diagnosis should be sought to confirm the diagnosis.
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Affiliation(s)
- Preeya Kundasamy
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Ben Kemp
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Daniel Kearns
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Andrew McCallum
- Department of Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sarfraz Nazir
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Paul C Lyon
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Kulchavenya EV, Kholtobin DP. Dynamics of the structure of renal tuberculosis over 20 years. TERAPEVT ARKH 2022; 94:1239-1245. [PMID: 37167160 DOI: 10.26442/00403660.2022.11.201930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Indexed: 12/27/2022]
Abstract
Background. Tuberculosis is a serious medical and social problem that does not lose its importance, despite all the advances in pharmacology and surgery. Diagnosis of urogenital tuberculosis (UGTB), as a rule, is delayed due to low index of suspicion to tuberculosis and the absence of pathognomonic symptoms.
Aim. Determining the change in the ratio of clinical forms of renal tuberculosis from 1999 to 2020.
Materials and methods. A retrospective cohort comparative non-interventional study on the spectrum of the incidence of extrapulmonary tuberculosis (EPTB) was carried out. Among all 13852 extrapulmonary tuberculosis patients which were diagnosed from 1999 to 2020, patients with renal tuberculosis were selected, and the spectrum of their clinical forms in three periods was analyzed: 1st period 19992004 (1155 patients), second period 20052014 (2657 patients), and the third period 20152020 (671 patients). The clinical features of nephrotuberculosis in 88 patients was also estimated.
Results. Over the 20 years of the analyzed period, the number of patients with UGTB decreased by 80.6%; for the year of the COVID-19 pandemic, this figure fell by another third. In the first period, destructive complicated forms of nephrotuberculosis prevailed (922 patients 79.8%), while the so-called "minor forms" were diagnosed in 233 patients (20.2%). In the second period, the situation was statistically significantly more favorable: the proportion of destructive and complicated forms of renal tuberculosis decreased to 43.8% (1124 patients), "small forms" were diagnosed in 1443 patients (56.2%). In the third period, destructive and complicated forms of nephrotuberculosis were diagnosed in 531 patients (77.6%), and the proportion of "small forms" in comparison with the previous period decreased by half, to 22.4%. Analysis of the clinical features of renal tuberculosis, depending on the prevalence of the destruction, showed that an asymptomatic course is possible, and pain, dysuria, intoxication and renal colic are present with different frequencies, and the clinical picture of tuberculosis of the renal parenchyma differs significantly from the clinical picture of tuberculous papillitis, cavernous nephrotuberculosis and symptoms of renal tuberculosis as whole.
Conclusion. Currently, there is no screening on urogenital tuberculosis at all. Patients are diagnosed by referral, with a long history, after receiving multiple courses of antibacterial treatment; mainly through the pathomorphological examination of the operating material. Thus, a sharp decrease in the proportion of UGTB patients does not mean the disappearance of tuberculosis of this localization, but only states the tragic defects in timely diagnosis and low index of suspicion of medical doctors in relation to UGTB.
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Extrapulmonary tuberculosis mortality according to clinical and point of care ultrasound features in Mozambique. Sci Rep 2022; 12:16675. [PMID: 36198860 PMCID: PMC9534934 DOI: 10.1038/s41598-022-21153-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022] Open
Abstract
In resource-limited settings, point-of-care ultrasound (POCUS) has great potential to support the timely diagnosis of extrapulmonary tuberculosis (EPTB). We aim to determine the in-hospital mortality due to EPTB according to clinical and POCUS features and risk factors in newly diagnosed patients hospitalized for EPTB in Chókwè district, Mozambique. We analyzed routinely collected data from paper medical files and electronic POCUS records of EPTB in infected patients aged 15 years or older and admitted to Carmelo Hospital of Chókwè from 2016 to 2020. Kaplan–Meier survival curves and adjusted Cox regression analyses were used to model predictors of mortality and time to death. The 390 included in-patients with EPTB and POCUS data contributed a total of 6240 in-hospital person-days of observation. The overall mortality rate was 2.16 per 100 person-days. Adjusted Cox regression showed a higher risk of death in those with abdominal tenderness (adjusted hazard ratio [aHR] 1.61, 95% confidence interval [CI] 1.00–2.82, p = 0.050), antiretroviral treatment (ART) for more than 90 days (aHR 4.03, 95% CI 1.50–10.78, p = 0.006), and mixed patterns on kidney POCUS (aHR 2.91, 95% CI 1.38–6.10, p = 0.005). An optimal immunovirological response to ART was a protective factor against death [aHR] 0.12, 95% CI 0.04–0.35, p < 0.001). Variables associated with an increased risk of death were male gender, abdominal pain, ART for more than three months (with immunovirological failure or non-response to ART) and having a mixed pattern of kidney POCUS characteristics. Early detection of these risk factors may have a direct impact on reducing TB mortality, and the POCUS approach as a complementary diagnostic method for EPTB provides a simple, feasible and affordable intervention in resource-limited settings like Mozambique.
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Chandran S, Rahman A, Norris JM, Tiberi S, Kunst H. Diagnostic pitfalls of urogenital tuberculosis. Trop Med Int Health 2021; 26:753-759. [PMID: 33817915 DOI: 10.1111/tmi.13583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To describe characteristics, details of diagnosis and outcomes of urogenital tuberculosis (UGTB) in a low-prevalence country. METHODS We conducted a retrospective observational study of 37 consecutive patients diagnosed with UGTB between 1st January 2014 and 31st October 2019 in an East London hospital. RESULTS 68% (25/37) of patients were male and the median age was 42 years (IQR 34-55). 89% (33/37) of patients were born outside the United Kingdom with 65% (24/37) born in the South Asian region. Renal (32.4%), epididymal (24.3%) and endometrial TB (21.6%) were the most prevalent forms of UGTB. Only 13.5% of UGTB patients had concurrent pulmonary TB. The median length of time from symptom onset to treatment was 163 days, while endometrial TB had an average delay to diagnosis of 564 days. Approximately half of patients with UGTB were culture positive (51.4%). However, 70% of early morning urines (EMUs) sent in urinary TB were culture positive. 11 patients (30.6%) underwent two or more invasive procedures, such as biopsy to obtain specimen samples. The mean treatment length for all UGTB cases was 7.3 months (SD 3.1). Notably, 25% of patients with endometrial TB required surgery despite antituberculous treatment. CONCLUSIONS UGTB is challenging to diagnose as early disease is often asymptomatic. Clinicians faced with non-specific symptoms, or features suggestive of urogenital malignancy amongst patients from TB-endemic areas, should maintain a high suspicion of UGTB.
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Affiliation(s)
- Shruthi Chandran
- Department of Infection, Royal London Hospital, Barts NHS Health Trust, London, UK
| | - Ananna Rahman
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - Joseph M Norris
- UCL Division of Surgery & Interventional Science, University College London, London, UK
| | - Simon Tiberi
- Department of Infection, Royal London Hospital, Barts NHS Health Trust, London, UK.,Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - Heinke Kunst
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
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Ismatov B, Sereda Y, Sahakyan S, Gadoev J, Parpieva N. Hospitalizations and Treatment Outcomes in Patients with Urogenital Tuberculosis in Tashkent, Uzbekistan, 2016-2018. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094817. [PMID: 33946457 PMCID: PMC8124920 DOI: 10.3390/ijerph18094817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 11/16/2022]
Abstract
Despite the global shift to ambulatory tuberculosis (TB) care, hospitalizations remain common in Uzbekistan. This study examined the duration and determinants of hospitalizations among adult patients (≥18 years) with urogenital TB (UGTB) treated with first-line anti-TB drugs during 2016–2018 in Tashkent, Uzbekistan. This was a cohort study based on the analysis of health records. Of 142 included patients, 77 (54%) were males, the mean (±standard deviation) age was 40 ± 16 years, and 68 (48%) were laboratory-confirmed. A total of 136 (96%) patients were hospitalized during the intensive phase, and 12 (8%) had hospital admissions during the continuation phase of treatment. The median length of stay (LOS) during treatment was 56 days (Interquartile range: 56–58 days). LOS was associated with history of migration (adjusted incidence rate ratio (aIRR): 0.46, 95% confidence interval (CI): 0.32–0.69, p < 0.001); UGTB-related surgery (aIRR: 1.18, 95% CI: 1.01–1.38, p = 0.045); and hepatitis B comorbidity (aIRR: 3.18, 95% CI: 1.98–5.39, p < 0.001). The treatment success was 94% and it was not associated with the LOS. Hospitalization was almost universal among patients with UGTB in Uzbekistan. Future research should focus on finding out what proportion of hospitalizations were not clinically justified and could have been avoided.
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Affiliation(s)
- Bakhtiyor Ismatov
- Republican Specialized Scientific and Practical Medical Center of Tuberculosis and Pulmonology, Tashkent 100086, Uzbekistan;
- Correspondence: ; Tel.: +998-909-669-960
| | | | - Serine Sahakyan
- Armenia and Tuberculosis Research and Prevention Center NGO, Yerevan 0034, Armenia;
| | - Jamshid Gadoev
- World Health Organization (WHO) Country Office in Uzbekistan, Tashkent 100100, Uzbekistan;
| | - Nargiza Parpieva
- Republican Specialized Scientific and Practical Medical Center of Tuberculosis and Pulmonology, Tashkent 100086, Uzbekistan;
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Hayward SE, Rustage K, Nellums LB, van der Werf MJ, Noori T, Boccia D, Friedland JS, Hargreaves S. Extrapulmonary tuberculosis among migrants in Europe, 1995 to 2017. Clin Microbiol Infect 2020; 27:1347.e1-1347.e7. [PMID: 33352301 PMCID: PMC8437049 DOI: 10.1016/j.cmi.2020.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 11/18/2022]
Abstract
Objectives The proportion of tuberculosis (TB) cases occurring in migrants in Europe is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality, yet its extent in migrant populations is unclear. We assessed patterns of extrapulmonary TB in migrants across the European Union (EU)/European Free Trade Association (EFTA). We investigated the proportion of extrapulmonary TB cases among migrants versus non-migrants, and variations by specific site of disease, reporting European region, and migrant region of origin. Methods We carried out a cross-sectional secondary database analysis, utilizing 23 years of data collected between 1995 and 2017 from the European Surveillance System of the European Centre for Disease Prevention and Control for 32 EU/EFTA countries. Results In total, 1 270 896 TB cases were included, comprising 326 987 migrants (25.7%) and 943 909 non-migrants (74.3%). Of TB cases among migrants, 45.2% (n = 147 814) were extrapulmonary compared to 21.7% (n = 204 613) among non-migrants (p < 0.001). Lymphatic, bone/joint and peritoneal/digestive TB were more common among migrant than non-migrant extrapulmonary cases. A lower proportion of extrapulmonary TB was seen in Eastern Europe (17.4%, n = 98 656 of 566 170) and Southern Europe (29.6%, n = 62 481 of 210 828) compared with Western (35.7%, n = 89 498 of 250 517) and Northern Europe (41.8%, n = 101 792 of 243 381). Migrants from South-East Asia and Sub-Saharan Africa were at highest risk of extrapulmonary disease, with 62.0% (n = 55 401 of 89 353) and 54.5% (n = 38 327 of 70 378) of cases, respectively, being extrapulmonary. Conclusions Among TB cases in the EU/EFTA, extrapulmonary disease is significantly more common in migrants than in non-migrants. There is a need to improve clinical awareness of extrapulmonary TB and to integrate its detection into screening programmes.
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Affiliation(s)
- Sally E Hayward
- Institute for Infection and Immunity, St George's, University of London, London, UK; Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - Kieran Rustage
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Laura B Nellums
- Institute for Infection and Immunity, St George's, University of London, London, UK; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Teymur Noori
- European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Delia Boccia
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jon S Friedland
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Sally Hargreaves
- Institute for Infection and Immunity, St George's, University of London, London, UK
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Tal R, Lawal T, Granger E, Simoni M, Hui P, Buza N, Pal L. Genital tuberculosis screening at an academic fertility center in the United States. Am J Obstet Gynecol 2020; 223:737.e1-737.e10. [PMID: 32497612 DOI: 10.1016/j.ajog.2020.05.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 05/06/2020] [Accepted: 05/27/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Infertility is a common presentation of female genital tuberculosis in endemic areas. Female genital tuberculosis-related maternal and neonatal complications have increased in recent years after assisted reproductive technology treatments. Despite rising emigration rates to the United States, guidelines to identify those with latent tuberculosis or female genital tuberculosis in fertility centers do not exist. OBJECTIVE This study aimed to characterize the prevalence of female genital tuberculosis in infertile patients at our academic fertility center. STUDY DESIGN This is a prospective cohort study. All patients presenting for infertility evaluation between January 2014 and January 2017 were assessed for risk factors for latent tuberculosis. Patients at risk for latent tuberculosis underwent screening using QuantiFERON-TB Gold serum assay. QuantiFERON-TB Gold-positive patients underwent further testing for female genital tuberculosis consisting of endometrial biopsy with histopathologic examination by a clinical pathologist, polymerase chain reaction for tuberculosis, and culture for acid-fast Mycobacterium tuberculosis. RESULTS Twenty-five of 323 infertility patients (7.7%) screened for latent tuberculosis had positive QuantiFERON-TB Gold results. A greater number of patients with a positive test result for QuantiFERON-TB Gold were foreign born than those with a negative test result for QuantiFERON-TB Gold (92% vs 29%; P<.001). Of note, the QuantiFERON-TB Gold-positive population had a higher incidence of both recurrent pregnancy loss (28% vs 7%; P=.003) and Asherman syndrome (8% vs 0.3%; P<.001). Among those with a positive test result for QuantiFERON-TB Gold, chest x-ray was abnormal in only 2 patients (8.0%). Endometrium evaluation revealed abnormalities in 2 patients (8.0%), in whom chest x-ray was normal, with 1 showing evidence of female genital tuberculosis. This was indicated by histology consistent with chronic granulomatous endometritis and positive endometrial testing for tuberculosis by polymerase chain reaction, acid-fast bacilli smear, and culture for Mycobacterium tuberculosis. CONCLUSION Although the prevalence of female genital tuberculosis in infertile women in the United States seems to be low, this study indicates that it can be underdiagnosed without utilization of multiple diagnostic modalities including endometrial sampling. Given the potential for serious maternal and neonatal morbidity in affected patients utilizing assisted reproductive technology, we propose that all at-risk women seeking infertility care in the United States be screened for latent tuberculosis. In patients who screen positive, endometrial biopsy should be obtained for evaluation by histology, polymerase chain reaction, and culture for Mycobacterium tuberculosis to rule out female genital tuberculosis before infertility treatments are initiated.
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Sharma JB, Sharma E, Sharma S, Singh J, Chopra N. Genital tb-diagnostic algorithm and treatment. Indian J Tuberc 2020; 67:S111-S118. [PMID: 33308655 DOI: 10.1016/j.ijtb.2020.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/09/2020] [Indexed: 10/23/2022]
Abstract
Female genital tuberculosis (FGTB) is a common cause of infertility in India but its diagnosis remains elusive due to paucibacillary nature of disease. Traditional methods of diagnosis include demonstration of acid fast bacilli on endometrial or peritoneal biopsy or epithelioid granuloma on the biopsy or positive gene Xpert on the biopsy, but they are positive in small percentage of cases only missing diagnosis in many cases. Positive polymerase chain reaction (PCR) alone is not taken for diagnosis due to high false positivity. Diagnostic laparoscopy and hysteroscopy can detect many cases by direct demonstration of TB lesions. Composite reference standard is a useful method to diagnose FGTB. This review discusses various diagnostic modalities including endometrial or peritoneal biopsy to detect acid fast bacilli on microscopic or culture or epithelioid granuloma, role of PCR, role of radiological imaging (hysterosalpingography, ultrasound, CT scan, MRI and PET-CT scan) and role of endoscopic techniques (laparoscopy and hysteroscopy) in diagnosis of FGTB including role of composite reference standard. The International and National studies highlight the role of composite reference standard and its components like demonstration of AFB on microscopy or culture of endometrial or peritoneal biopsy or epithelioid granuloma or gene Xpert or PCR or latest tests like loop-mediated isothermal amplification (TB-LAMP) test and other newer molecular methods like Xpert Ultra for diagnosis of FGTB. It also detects role of endoscopy in FGTB and role of diagnostic algorithm for diagnosis of FGTB. Treatment is with four primary drugs (rifampicin, isoniazid, ethambutol and pyrazinamide) for two months followed by three drugs (rifampicin, isoniazid and ethambutol) daily orally for 4 months for drug sensitive FGTB. Shorter Multidrug-resistant TB (MDR-TB) regimen is given for Rifampicin resistant (RR)/MDR confined to only FGTB while longer all oral regimen is given for RR/MDR with or without additional drug resistance, HIV seropositives with FGTB or involvement of other sites or pulmonary TB (PTB) along with FGTB. Composite reference standard which combines various diagnostic modalities is a useful strategy to diagnose FGTB.
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Affiliation(s)
- Jai Bhagwan Sharma
- Professor, Department of Obstetrics & Gynecology, All India Institute of Medical Sciences, New Delhi, India.
| | - Eshani Sharma
- Senior Research Fellow, Department of Obstetrics & Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sangeeta Sharma
- Professor and Head, Department of Paediatrics, National Institute of Tuberculosis& Respiratory Diseases, New Delhi, India
| | - Janmeeta Singh
- Research Officer, Department of Obstetrics & Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Namita Chopra
- Medical Officer, Department of Obstetrics & Gynecology, Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, India
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Hammami F, Koubaa M, Ben Ayed H, Rekik K, Ben Jemaa M, Ben Hmida M, Trigui M, Marrakchi C, Dammak J, Ben Jemaa M. Update on urogenital tuberculosis in Southern Tunisia: a review of a 26-year period. Germs 2020; 10:150-156. [PMID: 33134192 DOI: 10.18683/germs.2020.1200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 11/08/2022]
Abstract
Introduction Tuberculosis affects commonly the lungs, but any other organs can be affected as well. Urogenital tuberculosis is usually misdiagnosed. In this perspective, we aimed to give an update on the epidemiological, clinical and evolutionary features of urogenital tuberculosis in Southern Tunisia. Methods We conducted a retrospective study including all patients with extrapulmonary tuberculosis notified during the period from 1992 to 2017 in Southern Tunisia. We specified the particularities of urogenital tuberculosis cases, and we compared them with other extrapulmonary tuberculosis cases. Results Overall, we analyzed 240 cases with urogenital tuberculosis, among 1702 patients with extrapulmonary tuberculosis (14.1%). There were 121 women (50.4%). The mean age was 49±17 years. Multifocal tuberculosis was noted in 29 cases (12.1%). There were 169 cases with urinary tract tuberculosis (70.4%). Chronological trends analysis showed that the median age at diagnosis increased significantly (Rho=0.41; p=0.039) and the number of urogenital tuberculosis declined during the study period, without a statistical significance (Rho = -0.07; p=0.721). Compared to other extrapulmonary tuberculosis sites, patients aged 60 years and above (OR=2.7; p<0.001) and coming from rural areas (OR=1.4; p=0.021) were more frequently diagnosed with urogenital tuberculosis. Treatment duration was significantly longer in patients with urogenital tuberculosis (10.13±3.79 vs 9.20±3.77 months; p<0.001). As for the disease evolution, relapse was significantly more frequent in patients with urogenital tuberculosis (OR=4.1; p=0.045). Conclusions Although decreasing trends over time were noted, the prognosis of urogenital tuberculosis was more severe compared to other extrapulmonary tuberculosis sites.
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Affiliation(s)
- Fatma Hammami
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Makram Koubaa
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Houda Ben Ayed
- MD, Community Health and Epidemiology Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Khaoula Rekik
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Maissa Ben Jemaa
- MD, Community Health and Epidemiology Department, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Mariem Ben Hmida
- MD, Community Health and Epidemiology Department, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Maroua Trigui
- MD, Community Health and Epidemiology Department, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Chakib Marrakchi
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Jamel Dammak
- MD, Community Health and Epidemiology Department, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Mounir Ben Jemaa
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
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13
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Ponnayyan NK, Ganapath AS, Ganapathy V. Spectrum of tuberculosis in urology: Case series and review of the literature. Urol Ann 2020; 12:107-111. [PMID: 32565645 PMCID: PMC7292423 DOI: 10.4103/ua.ua_121_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/11/2019] [Indexed: 11/12/2022] Open
Abstract
Urologists are confronted with various forms of extrapulmonary tuberculosis (TB) having an atypical presentation. The disease presents late with complications and sequelae. Four cases of extrapulmonary TB who presented to the urology department are reported here. The cases reported are TB adrenalitis, tuberculous cystitis, renal TB, and TB prostatitis. The prsentation of these cases shows GUTB as being a great imitator of other diseases. So there is a need for a very high index of suspicion for early diagnosis and to avoid misdiagnosis to prevent the devastating sequelae like organ damage. Furthermore, there is a need to develop better diagnostic tools for TB. Multidrug chemotherapy and judicious use of surgery form the mainstay of management.
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Affiliation(s)
| | | | - Venugopal Ganapathy
- Department of Urology, Government Medical College, Trivandrum, Kerala, India
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14
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K Mehta P, Kamra E. Recent trends in diagnosis of urogenital tuberculosis. Future Microbiol 2020; 15:159-162. [DOI: 10.2217/fmb-2019-0323] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Promod K Mehta
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak 124001, India
| | - Ekta Kamra
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak 124001, India
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15
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Oluogun W, Eziyi A, Adedokun K, Oyeniyi G. Prostate tuberculosis: A rare complication of pulmonary tuberculosis with malignant features mimicking prostate cancer. UROLOGICAL SCIENCE 2020. [DOI: 10.4103/uros.uros_80_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Abstract
In the context of refugee migrations infectious diseases are being more frequently diagnosed, which the responsible physicians as well as urologists have never seen before. This is due to the poorer health and hygiene conditions in the country of origin, during the flight and in the refugee camps. In Europe increasing incidences of tuberculosis, schistosomiasis and scabies have recently been observed. Tuberculosis and schistosomiasis are often accompanied by unspecific symptoms or can resemble normally encountered urological diseases. Due to the highly contagious nature of scabies, a screening of new arrivals is recommended. A timely differential diagnostic inclusion of these disease patterns is enormously important. Despite the reduction in the numbers of asylum applications in Germany, a higher number of unregistered migrants is generally assumed, who also elude the healthcare system and can therefore contribute to the spread of these rare infectious diseases.
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Affiliation(s)
- K Bausch
- Department Urologie, Universitätsspital Basel, Basel, Schweiz
- Universität Basel, Basel, Schweiz
| | - E Kulchavenya
- Urogenital Department, Novosibirsk Research TB Institution, Novosibirsk, Russland
| | - F Wagenlehner
- Klinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Giessen, Giessen, Deutschland
| | - G Bonkat
- Universität Basel, Basel, Schweiz.
- Merian Iselin Klinik, Centre of Biomechanics & Calorimetry, Alta Uro AG, Centralbahnplatz 6, 4051, Basel, Schweiz.
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17
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Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol 2019; 16:573-598. [PMID: 31548730 DOI: 10.1038/s41585-019-0228-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
Tuberculosis (TB) is the most common cause of death from infectious disease worldwide. A substantial proportion of patients presenting with extrapulmonary TB have urogenital TB (UG-TB), which can easily be overlooked owing to non-specific symptoms, chronic and cryptic protean clinical manifestations, and lack of clinician awareness of the possibility of TB. Delay in diagnosis results in disease progression, irreversible tissue and organ damage and chronic renal failure. UG-TB can manifest with acute or chronic inflammation of the urinary or genital tract, abdominal pain, abdominal mass, obstructive uropathy, infertility, menstrual irregularities and abnormal renal function tests. Advanced UG-TB can cause renal scarring, distortion of renal calyces and pelvic, ureteric strictures, stenosis, urinary outflow tract obstruction, hydroureter, hydronephrosis, renal failure and reduced bladder capacity. The specific diagnosis of UG-TB is achieved by culturing Mycobacterium tuberculosis from an appropriate clinical sample or by DNA identification. Imaging can aid in localizing site, extent and effect of the disease, obtaining tissue samples for diagnosis, planning medical or surgical management, and monitoring response to treatment. Drug-sensitive TB requires 6-9 months of WHO-recommended standard treatment regimens. Drug-resistant TB requires 12-24 months of therapy with toxic drugs with close monitoring. Surgical intervention as an adjunct to medical drug treatment is required in certain circumstances. Current challenges in UG-TB management include making an early diagnosis, raising clinical awareness, developing rapid and sensitive TB diagnostics tests, and improving treatment outcomes.
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18
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Multicentre evaluation of Xpert MTB/RIF assay in detecting urinary tract tuberculosis with urine samples. Sci Rep 2019; 9:11053. [PMID: 31363115 PMCID: PMC6667469 DOI: 10.1038/s41598-019-47358-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 07/12/2019] [Indexed: 01/11/2023] Open
Abstract
Genitourinary tuberculosis (GUTB) accounts for up to 40% of extrapulmonary tuberculosis cases. Rapid tests for GUTB are urgently needed because it is often associated with delayed health-care seeking, leading to serious consequences. This study evaluated the performance of the Xpert MTB/RIF assay in the rapid diagnosis of urinary tract tuberculosis (UTB) and rifampicin-resistant tuberculosis with urine specimens. In all, 302 patients were included from four hospitals in China. Suspected UTB patients were tested with Xpert, smear, and MGIT 960 culture. Drug susceptibility testing (DST) was conducted for culture-positive cases. The performance of the assays was evaluated against MGIT 960 culture and a composite reference standard (CRS). Among all participants, 150 (49.7%) had CRS-positive UTB, of whom 36 (24.0%) were culture-confirmed. Against culture, Xpert and smear achieved a sensitivity of 94.4% (95% CI: 81.3-99.3%) and 22.2% (95% CI: 10.1-39.2%), respectively. Against CRS, the sensitivity of Xpert, smear and culture was 41.3% (95% CI: 33.4-49.7%), 7.3% (95% CI: 3.7-12.7%), and 24.0% (95% CI: 17.4-31.6%). Xpert had better performance than smear and culture in detecting UTB from urine samples and could be considered for the diagnosis of UTB. Moreover, Xpert showed better performance than MGIT 960-based DST using urine culture.
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19
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Disseminated Tuberculosis Presenting as Chronic Orchiepididymitis in a Military Trainee: A Case Report and Review of the Literature. Case Rep Infect Dis 2018; 2018:7316097. [PMID: 30402306 PMCID: PMC6192136 DOI: 10.1155/2018/7316097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 07/12/2018] [Indexed: 11/17/2022] Open
Abstract
Orchiepididymitis is a clinical diagnosis. The acute form secondary to sexually transmitted or enteric pathogens is well known to primary care providers. However, chronic orchiepididymitis may be secondary to genitourinary tuberculosis (TB), and physicians in countries with a low prevalence of TB might not consider it in their differential diagnosis. Indeed, cognitive errors, such as anchoring or availability bias, may contribute to a delayed diagnosis of genitourinary TB. We present a case of chronic orchiepididymitis as a result of disseminated TB in a Cameroonian male who was visiting the United States for military training. He experienced diagnostic delay and was ultimately diagnosed by orchiectomy. Early consideration of a diagnosis of TB for chronic or recurrent orchiepididymitis in a patient with epidemiologic risk factors is of utmost importance because delayed diagnosis could lead to organ loss.
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20
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Jagodziński J, Zielonka TM, Peplińska K, Życińska K. Tuberculosis of the Urogenital Tract in Adults in a Tertiary Referral Center. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1040:29-37. [PMID: 29392579 DOI: 10.1007/5584_2017_103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The genitourinary system is the main location of extrapulmonary tuberculosis. In Poland, it occupies the third place after tuberculosis of the pleura and lymph nodes. The aim of this study was to evaluate the prevalence and characteristics of tuberculosis in the urogenital tract in adult patients in a tertiary referral center in the years 2007-2015. The retrospective study included 87 patients, 42 women and 45 men. The average age was 62 ± 15 years. Changes in the urinary tract were diagnosed in 91% of women and 64% of men. Testicular tuberculosis was found in ten men, prostate tuberculosis in five, and in individual cases tuberculosis of the epididymis, scrotum, uterus, and the fallopian tube were found. The diagnosis was confirmed by bacteriological methods in 47% of patients, by histopathological in 41%, and by molecular methods in 23% of patients. In 84% of patients urological or gynecological interventions had to be applied. Patients were burdened with a number of urological diseases or diseases affecting other systems which hampered the diagnosis of tuberculosis. Antituberculosis treatment gave good results. Urogenital tuberculosis is a multivariate disease and a standard unified approach is impossible.
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Affiliation(s)
- Jacek Jagodziński
- Mazovian Center for the Treatment of Lung Diseases and Tuberculosis in Otwock, Otwock, Poland
| | - Tadeusz M Zielonka
- Department of Family Medicine, Medical University of Warsaw, 1A Banacha Street, 02-097, Warsaw, Poland.
| | - Krystyna Peplińska
- Department of Internal Medicine and Cardiology, Solec Hospital, Warsaw, Poland
| | - Katarzyna Życińska
- Department of Family Medicine, Medical University of Warsaw, 1A Banacha Street, 02-097, Warsaw, Poland
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21
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Kulchavenya E, Cherednichenko A. Urogenital tuberculosis, the cause of ineffective antibacterial therapy for urinary tract infections. Ther Adv Urol 2017; 10:95-101. [PMID: 29662539 DOI: 10.1177/1756287217745772] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/25/2017] [Indexed: 01/29/2023] Open
Abstract
Background Urogenital tuberculosis (UGTB) is one of the great imitators; it is commonly masked by urinary tract infections (UTIs). We aimed to estimate how many UGTB patients were among patients with a long history of UTIs. Material and Methods A total of 244 patients with recurrent UTIs and suspected UGTB were enrolled in an open, noncomparative prospective study. Their urine and expressed prostate secretion or ejaculate were cultured (a total of 1446 samples), and 421 isolates with growth of ⩾104 colony-forming units (CFU)/ml were investigated for drug resistance. Typically, UGTB diagnosis is made by individual case. Results All 244 patients had a long history of recurrent UTIs (on average, 7.9 ± 3.4 years); all received at least five courses of antibacterial therapy without good result. UGTB was diagnosed in 63 (25.8%), and in 41 of these (65.1%), there was comorbidity of UTI and UGTB. Of 1446 samples investigated, 421 (29.1%) were positive, and 1025 were negative. Escherichia coli was found in 57.3% of gram-negative microflora and in 29.0% only among all uropathogens. E. coli was resistant to amoxicillin/clavulanate in 51.5-57.1%, to cefotaxime in 50.0-52.0%, to gentamycin in 33.3-59.5%, to ciprofloxacin in 63.2-66.7%, to levofloxacin in 54.8-45.2%, and to nitrofurantoin in 23.5-20.8% in 2015 and 2016, respectively. If, in 2015, all isolates of E. coli were susceptible to imipenem, in 2016, 7.1% of strains were resistant to this antibiotic. Level of drug-resistance was higher in 2016, excluding only levofloxacin and nitrofurantoin. Conclusions Total prevalence of UGTB among UTI patients with poor results of antibacterial therapy was 25.8%. Comorbidity of UTI and UGTB was diagnosed in 65.1%.
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Affiliation(s)
- Ekaterina Kulchavenya
- Federal State Budgetary Institution 'The Novosibirsk Tuberculosis Research Institute (NTRI)' of the Ministry of Health of the Russian Federation, Novosibirsk Medical University, Russian Federation
| | - Andrey Cherednichenko
- Federal State Budgetary Institution 'The Novosibirsk Tuberculosis Research Institute (NTRI)' of the Ministry of Health of the Russian Federation, Russian Federation
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22
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Altez-Fernandez C, Seas C, Zegarra L, Ugarte-Gil C. Diseases masking and delaying the diagnosis of urogenital tuberculosis. Ther Adv Urol 2016; 8:234. [PMID: 27247632 DOI: 10.1177/1756287216638592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Carlos Altez-Fernandez
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Avenida Honorio Delgado s/n San Martín de Porres, Lima, Peru
| | - Carlos Seas
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Luis Zegarra
- Servicio de Urología, Hospital Nacional Cayetano Heredia, Lima, Peru
| | - Cesar Ugarte-Gil
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
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