Therapy duration and long-term outcomes in extra-pulmonary tuberculosis

Demographic, clinical and laboratory characteristics of extrapulmonary tuberculosis: Eight-year results of a multicenter retrospective study in Turkey

Extrapulmonary tuberculosis (EPTB) is an important public health problem due to its diverse clinical presentations, diagnostic complexities, and significant impact on patient outcomes and public health. Our study aimed to understand the sociodemographic, clinical, and laboratory characteristics as well as diagnostic and treatment modalities of adult patients with EPTB. This is a multicentric retrospective study that covers patients with EPTB cases followed up from January 2015 to December 2022 among tuberculosis (TB) dispensaries and Infectious Diseases and Clinical Microbiology clinics of 15 hospitals located in various regions of Turkey. The study included 64.6% women with a mean age of 44 years and a mortality rate of 3.5% within 1 year of diagnosis. Initial constitutional symptoms were predominantly fatigue (57%) and anorexia (53.7%). The most commonly affected sites were the lymph nodes (49.1%) and pleura (9.7%). The lumbar region was particularly involved in cases with spinal TB. Diagnostic findings included acid-fast bacilli positivity in 27.5% of cases, tuberculosis polymerase chain reaction positivity in 41%, elevated adenosine deaminase levels in 91.2% (especially in pleural and peritoneal fluids), and mycobacterial culture positivity in 40.9%. Pathology slides showed granulomatous inflammation in 97.7%. Increased C-reactive protein (CRP) levels correlated with the number of organs affected. Anti-TB treatment-related hepatotoxicity was detected in 8.9% of patients. In this study, it is important to note that the lumbar region is predominantly affected with involvement in spinal region. CRP level was consistent with the number of organ involvements and was one of the most critical results of this study.

Novelty of Physiotherapy Protocols in a Classic Case of Extrapulmonary Tuberculosis in a 35-Year-Old Male Patient: A Case Report

Tuberculosis is the most frequent cause of death, specifically caused by a single infectious agent, Mycobacterium tuberculosis. There are two types of tuberculosis: pulmonary tuberculosis and extrapulmonary tuberculosis. Patients with extrapulmonary tuberculosis often have reduced lung function due to the disease's structural abnormalities, which also significantly impair their quality of life. The suggested standard of care for the treatment of extrapulmonary tuberculosis patients is pulmonary rehabilitation. A 35-year-old male patient who complained of shortness of breath, dry cough, and on-and-off fever diagnose with extrapulmonary tuberculosis was the subject of the case study. The patient had extrapulmonary tuberculosis with a history of pleural effusion, which was managed with proper medications. After increasing symptoms of the disease, the patient was referred for pulmonary rehabilitation. Physiotherapy protocol includes breathing exercises, relaxation techniques, and mobility exercises for the upper limb and lower limb. Effective physical rehabilitation was necessary to minimize complications and allow him to resume daily activities. Several outcome measures, like the dyspnea scale, visual analog scale, six-minute walk test, and World Health Organization-Quality of Life (WHO-QOL) questionnaire, were used to monitor the patient's progress during rehabilitation. The benefits of physiotherapy protocols emphasize the need for tailored approaches to addressing individual patient needs for comprehensive recovery as it significantly enhances clinical, physical, psychosocial, and overall quality of life, making it crucial for patients with extrapulmonary tuberculosis. The protocols are beneficial to improve exercise capacity, muscle force, symptoms such as dyspnea, cough, and health-related quality of life in these patients. In this study, the focus was more on breathing exercises such as segmental breathing exercises for lung expansion and increasing air entry in the lungs followed by improving functional capacity and strength.

Seizures and epilepsy associated with central nervous system tuberculosis

Central nervous system (CNS) tuberculosis is a life-threatening condition that usually presents with seizures, particularly in children and HIV-infected patients. Tuberculous meningitis (TBM) and tuberculomas are the two forms of CNS tuberculosis that can present with seizures. Seizures usually resolve after successful treatment of the underlying infection. However, the success of the treatment is usually based on an early diagnosis. Delay in the treatment of CNS tuberculosis increases the risk of its associated complications, such as stroke. This would lead to the development of epilepsy. Early seizures may be related to meningeal irritation and cerebral edema, whereas late seizures are often associated with structural brain lesions that generally require more advanced and prolonged treatment. Risk factors associated with the development of epilepsy include young age, refractory seizures, tuberculoma, cortical involvement, epileptiform discharges, and residual lesions. Treatment of CNS tuberculosis is based on early initiation of appropriate anti-tuberculous drugs, antiseizure medications, and correction of associated predisposing factors. Finally, further research into the mechanisms of seizures and the development of epilepsy in CNS tuberculosis could help improve management of these conditions.

Clinical, laboratory and evolutionary features of abdominal tuberculosis in comparison with other forms of extrapulmonary tuberculosis

BACKGROUND/OBJECTIVES

Tuberculosis is a multisystem disease that might affect any organ. Abdominal tuberculosis (ABT) represents 5-17% from all extrapulmonary tuberculosis (EPT) sites. We aimed to study the clinical, laboratory and evolutionary features of ABT cases and to identify predictive factors associated with ABT.

METHODS

We conducted a retrospective study including all patients hospitalized in the infectious diseases department for EPT between 1991 and 2019. We studied the characteristics of ABT cases, and we compared them with other EPT cases.

RESULTS

We identified 519 patients with EPT, among whom 86 (16.6%) patients had ABT. There were 58 females (67.4%). Peritoneal tuberculosis was the most common clinical form of ABT (68.6%), followed by intestinal tuberculosis (18.6%). Patients aged 60 years and above were significantly less affected with ABT (odds ratio (OR) = 0.2; p = 0.001). The revealing systemic symptoms including fever (OR = 2.04; p = 0.006), weight loss (OR = 2.5; p < 0.001) and anorexia (OR = 1.7; p = 0.021) were significantly more frequent among ABT patients. Inflammatory markers including C-reactive protein levels (37 [10-89] mg/l vs 10 [4-57] mg/l; p < 0.001) and erythrocyte sedimentation rates (43 [15-95] mm/h vs 27 [15-60] mm/h; p = 0.044) were significantly higher among ABT cases. Multivariate logistic regression analysis showed that anorexia (adjusted OR (AOR) = 1.9; p = 0.015) and pulmonary involvement (AOR = 3.3; p = 0.002) were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal (AOR = 0.18; p = 0.001) and osteo-articular (AOR = 0.2; p = 0.01) sites, 40-59 (AOR = 0.2; p < 0.001) and ≥60 (AOR = 0.2; p < 0.001) age groups as well as hemoglobin rate (AOR = 0.7; p < 0.001) were independently associated with lower rate of ABT.

CONCLUSIONS

Anorexia and pulmonary involvement were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal and osteo-articular sites, 40-59 and ≥60 age groups and hemoglobin rate were independently associated with lower rate of ABT.

Machine learning reveals that Mycobacterium tuberculosis genotypes and anatomic disease site impacts drug resistance and disease transmission among patients with proven extra-pulmonary tuberculosis

Background

There is a general dearth of information on extrapulmonary tuberculosis (EPTB). Here, we investigated Mycobacterium tuberculosis (Mtb) drug resistance and transmission patterns in EPTB patients treated in the Tshwane metropolitan area, in South Africa.

Methods

Consecutive Mtb culture-positive non-pulmonary samples from unique EPTB patients underwent mycobacterial genotyping and were assigned to phylogenetic lineages and transmission clusters based on spoligotypes. MTBDRplus assay was used to search mutations for isoniazid and rifampin resistance. Machine learning algorithms were used to identify clinically meaningful patterns in data. We computed odds ratio (OR), attributable risk (AR) and corresponding 95% confidence intervals (CI).

Results

Of the 70 isolates examined, the largest cluster comprised 25 (36%) Mtb strains that belonged to the East Asian lineage. East Asian lineage was significantly more likely to occur within chains of transmission when compared to the Euro-American and East-African Indian lineages: OR = 10.11 (95% CI: 1.56–116). Lymphadenitis, meningitis and cutaneous TB, were significantly more likely to be associated with drug resistance: OR = 12.69 (95% CI: 1.82–141.60) and AR = 0.25 (95% CI: 0.06–0.43) when compared with other EPTB sites, which suggests that poor rifampin penetration might be a contributing factor.

Conclusions

The majority of Mtb strains circulating in the Tshwane metropolis belongs to East Asian, Euro-American and East-African Indian lineages. Each of these are likely to be clustered, suggesting on-going EPTB transmission. Since 25% of the drug resistance was attributable to sanctuary EPTB sites notorious for poor rifampin penetration, we hypothesize that poor anti-tuberculosis drug dosing might have a role in the development of resistance.

Artificial Intelligence in Pharmacoepidemiology: A Systematic Review. Part 1-Overview of Knowledge Discovery Techniques in Artificial Intelligence

Aim

To perform a systematic review on the application of artificial intelligence (AI) based knowledge discovery techniques in pharmacoepidemiology.

Study Eligibility Criteria

Clinical trials, meta-analyses, narrative/systematic review, and observational studies using (or mentioning articles using) artificial intelligence techniques were eligible. Articles without a full text available in the English language were excluded.

Data Sources

Articles recorded from 1950/01/01 to 2019/05/06 in Ovid MEDLINE were screened.

Participants

Studies including humans (real or simulated) exposed to a drug.

Results

In total, 72 original articles and 5 reviews were identified via Ovid MEDLINE. Twenty different knowledge discovery methods were identified, mainly from the area of machine learning (66/72; 91.7%). Classification/regression (44/72; 61.1%), classification/regression + model optimization (13/72; 18.0%), and classification/regression + features selection (12/72; 16.7%) were the three most frequent tasks in reviewed literature that machine learning methods has been applied to solve. The top three used techniques were artificial neural networks, random forest, and support vector machines models.

Conclusions

The use of knowledge discovery techniques of artificial intelligence techniques has increased exponentially over the years covering numerous sub-topics of pharmacoepidemiology.

Systematic Review Registration

Systematic review registration number in PROSPERO: CRD42019136552.

Extrapulmonary Tuberculosis in Denmark From 2009 to 2014; Characteristics and Predictors for Treatment Outcome

BACKGROUND

Extrapulmonary tuberculosis (EPTB) represents an increasing percentage of tuberculosis (TB) cases in Europe. However, strategies on TB prevention and successful treatment outcomes primarily target pulmonary TB. In this nationwide study, we present characteristics of EPTB, treatment outcomes, and predictors for unfavorable treatment outcomes.

METHODS

All patients diagnosed with EPTB from 2009 to 2014 were included. Logistic regression analyses were used to identify risk factors for unfavorable outcome. The following definitions were used: unfavorable outcome: the sum of treatment failed, lost to follow-up, and not evaluated; patient delay: time from TB-related symptom onset until first hospital contact related to TB; doctor delay: time from first TB-related contact in the health care system to start of TB treatment.

RESULTS

A total of 450 EPTB cases were notified, which represented 21.1% of all TB cases in Denmark. Immigrants accounted for 82.9%. Lymph nodes were the most common site of EPTB (55.4%) followed by pleural TB (13.4%). Patient delay was significantly longer among immigrants than Danes (60 vs 30 days; P < .01), whereas doctor delay was significantly longer among Danes (38.5 vs 28 days; P < .01). Treatment completion rates were high and reached 90.9% in 2014. Male gender (odds ratio [OR], 5.18; 95% confidence interval [CI], 1.79-15.04) and age 0-24 years (OR, 16.39; 95% CI, 2.02-132.64) were significantly associated with unfavorable outcome.

CONCLUSIONS

EPTB represented a significant number of all TB cases and was predominantly seen among younger immigrants in Denmark. To maintain high treatment completion rates, increased focus on male gender and young age is needed.

Pulmonary vs. extra-pulmonary tuberculosis hospitalizations in the US [1998-2014]

BACKGROUND

Few studies have explored the relative burden and trends in pulmonary (PTB) vs. extra-pulmonary (EPTB) tuberculosis in the United States using a nationally representative sample.

METHODS

This study examined trends in hospitalization rates, length-of-stay (LOS), in-hospital mortality and inflation-adjusted charges, for PTB vs. EPTB using the Nationwide/National Inpatient Sample (NIS) from 1998 to 2014. Descriptive and multivariable analyses (linear, negative binomial and logistic) were utilized adjusting for demographics, co-morbidity and hospital characteristics.

RESULTS

During the study period there were a survey-adjusted, estimated 258,631 PTB (75.5%), 76,476 EPTB (22.3%) and 7552 concurrent PTB and EPTB (2.2%) discharges. Whites accounted for 27.6% of PTB, 21.9% of EPTB and 17.6% of concurrent discharges; and self-pay or no insurance accounted for 22.2%, 18.4%, and 25.9%, respectively. EPTB was more common among blacks (22.5%), and combined TB more common among Hispanics (24.8%). Mean LOS was 11.4 days, 13.2 days, and 19.5 days; with mean nominal charges of $48,031, $62,255, and $89,364 for PTB, EPTB and combined TB respectively. Inpatient mortality for all three groups was approximately 5.7%. Miliary TB and TB of meninges and central nervous system were positively associated with mortality (odds ratios of 2.44 and 2.11, respectively), as was alcohol abuse (OR 1.21). Trend analyses showed decreased hospitalizations for all TB types, no change in LOS trends, decreased mortality for PTB and ETB and increased charges for PTB and ETB from 1998 to 2014. Increased utilization, higher charges and higher risk of mortality (to some extent) among the EPTB cases warrant improved methods for screening, diagnosis and treatment.

CONCLUSION

Though rates of TB hospitalization are declining, EPTB is becoming relatively more common and is more costly compared to pulmonary TB. Screening methods that focus on identification of ETB contrary to current practice guidelines are needed to aid ETB case finding.

Use of classification and regression tree (CART), to identify hemoglobin A1C (HbA1C) cut-off thresholds predictive of poor tuberculosis treatment outcomes and associated risk factors

Background

Rifampin-based therapy potentially exacerbates glycemic control among TB patients who are already at high risk of hyperglycemia. This impacts negatively to the optimal care of TB- diabetes mellitus co-affected patients. Classification and regression tree (CART), a machine-learning algorithm impervious to statistical assumptions is one of the ideal tools for clinical decision-making that can be used to identify hemoglobin A1C (HbA_1C) cut-off thresholds predictive of poor TB treatment outcomes in such populations.

Methods

340TB smear positive patients attending two peri-urban clinics were recruited and prospectively followed up for six months. Baseline HbA_1C and random blood glucose (RBG) levels were determined. CART was then used to identify cut-off thresholds and rank outcome predictors at end of therapy by determining Risk ratios (RR) and 95% confidence interval (CI) of each predictor threshold. Fractal geometry law explained effect of weight, while U-shaped curve explained effect of HbA_1C on these clinical outcomes.

Results

Of the 340 patients enrolled: 84%were cured, 7% completed therapy and 9% had unfavorable outcomes out of which 4% (n = 32) had microbiologic failure. Using CART HbA_1C identified thresholds were >2.95%, 2.95–4.55% and >4.55%, containing 8/11 (73%), 111/114 (97%) and 189/215 (88%) of patients who experienced favorable outcomes. RR for favorable outcome in patients with weight <53.25 Kg compared to >53.25 Kg was 0.61 (95% CI, 0.45–0.88) among patients with HbA1C >4.55%. Simulation of the CART model with 13 patients data failed therapy revealed that 8/11 (73%) of patients with HbA1C <2.95%, 111/114 (97%) with HbA_1C between 2.95% and 4.55% and 189/215 (88%) of patients with HbA1c >4.55% experienced microbiologic failure.

Conclusion

Using fractal geometry relationships to drug pharmacokinetics, low weight has profound influence on failure of anti-tuberculosis treatment among patients at risk for diabetes mellitus.

Optimal Clinical Doses of Faropenem, Linezolid, and Moxifloxacin in Children With Disseminated Tuberculosis: Goldilocks

Background. When treated with the same antibiotic dose, children achieve different 0- to 24-hour area under the concentration-time curves (AUC_0–24) because of maturation and between-child physiological variability on drug clearance. Children are also infected by Mycobacterium tuberculosis isolates with different antibiotic minimum inhibitory concentrations (MICs). Thus, each child will achieve different AUC_0–24/MIC ratios when treated with the same dose.

Methods. We used 10 000-subject Monte Carlo experiments to identify the oral doses of linezolid, moxifloxacin, and faropenem that would achieve optimal target exposures associated with optimal efficacy in children with disseminated tuberculosis. The linezolid and moxifloxacin exposure targets were AUC_0–24/MIC ratios of 62 and 122, and a faropenem percentage of time above MIC >60%, in combination therapy. A linezolid AUC_0–24 of 93.4 mg × hour/L was target for toxicity. Population pharmacokinetic parameters of each drug and between-child variability, as well as MIC distribution, were used, and the cumulative fraction of response (CFR) was calculated. We also considered drug penetration indices into meninges, bone, and peritoneum.

Results. The linezolid dose of 15 mg/kg in full-term neonates and infants aged up to 3 months and 10 mg/kg in toddlers, administered once daily, achieved CFR ≥ 90%, with <10% achieving linezolid AUC_0–24 associated with toxicity. The moxifloxacin dose of 25 mg/kg/day achieved a CFR > 90% in infants, but the optimal dose was 20 mg/kg/day in older children. The faropenem medoxomil optimal dosage was 30 mg/kg 3–4 times daily.

Conclusions. The regimen and doses of linezolid, moxifloxacin, and faropenem identified are proposed to be adequate for all disseminated tuberculosis syndromes, whether drug-resistant or -susceptible.

Determinant factors for mortality during treatment among tuberculosis patients: Cox proportional hazards model

BACKGROUND

Investigating the survival of tuberculosis (TB) patients is one of the main parts of the TB control program. It can be related to many factors. This study aimed to estimate the survival experience and its associated factors among these patients.

METHODOLOGY

All TB patients detected during March 2005 to 31 September 2014 were entered into this prospective cohort. Each patient was investigated from the diagnosis date and followed until the last available information during treatment. Data analysis was performed using Kaplan Meier and multivariate Cox regression models.

RESULTS

The survival experience of 2493 TB patients was investigated 73.7% of which were pulmonary type. Mean and median survival time were 6.5 and 6.2 months respectively. The incidence rate of death among patients during the treatment courses was 0.99 (95% confidence interval: 0.84-1.1) per 100 person-months. Controlling the confounders, the incidence (95% confidence interval) of death was significantly higher among men (HR=1.8; 1.2-2.6), diabetic patients (HR=1.7; 1.2-2.6), cancerous patients (HR=4.8; 2.6-8.8) and HIV positive patients (HR=22.1; 7.3-66.4).

CONCLUSION

This study showed that male gender, TB/HIV co-infection and concurrent development of TB and cancer were determinant factors of death during the treatment period of TB.

Hepatic and Intra-abdominal Tuberculosis: 2016 Update

Mycobacterium tuberculosis (TB) infection affects nearly 10 million people a year and causes 1.5 million deaths. TB is common in the immunosuppressed population with 12 % of all new diagnoses occurring in human immune deficiency virus (HIV)-positive patients. Extra-pulmonary TB occurs in 12 % of patients with active TB infection of which 3.5 % is hepatobiliary and 6-38 % is intra-abdominal. Hepatobiliary and intra-abdominal TB can present with a myriad of non-specific symptoms, and therefore, diagnosis requires a high level of suspicion. Accurate and rapid diagnosis requires a multidisciplinary team (MDT) approach using radiology, interventional radiology, surgery and pathology services. Treatment of TB is predominantly medical, yet surgery plays an important role in managing the complications of hepatobiliary and intra-abdominal TB.

Treatment of Active Tuberculosis in Chicago, 2008-2011: The Role of Public Health Departments

Objective

Evaluate differences in TB outcomes among different provider types in Chicago, IL.

Methods

We retrospectively reviewed all TB cases reported to the Chicago Department of Public Health (CDPH) from 2008 through 2011. Provider type was stratified into three groups: public, public-private, and private providers. Multivariate regression was used to evaluate treatment duration and time to sputum culture conversion. A Cox proportional hazard model was used to assess treatment completion.

Results

Of 703 cases, 203 (28.9%), 314 (44.7%), and 186 (26.5%) were treated by public, public-private and private providers, respectively. Adjusted regression showed private provider patients had a 48-day (95% CI 22.0–74.3) increase in treatment duration and a 30-day (95% C.I. 9.5–51.1) increase in time to sputum culture conversion. Cox model showed increased risk of remaining on treatment was associated with extra-pulmonary TB (aHR 0.78, 95% C.I. 0.62–0.98), being foreign-born (aHR 0.74, 95% C.I. 0.58–0.95), and any drug resistance (aHR 0.59, 95% C.I. 0.46–0.76). There were no differences in outcomes between public and public-private providers.

Conclusion

Patients treated solely in the private sector had prolonged time to sputum culture conversion and treatment duration which lead to increased cost for treatment, prolonged infectiousness, potential for transmission, and the possibility for increased medication side effects.

High proportion of extrapulmonary tuberculosis in a low prevalence setting: a retrospective cohort study

OBJECTIVES

The proportion of extrapulmonary tuberculosis (EPTB) cases in the United States (US) has been rising due to a slower rate of decline in EPTB compared to pulmonary tuberculosis (PTB). The purpose of this study was to characterise the clinical and treatment differences between EPTB and PTB patients, and identify patient factors associated with EPTB.

STUDY DESIGN

We performed a retrospective cohort study of active tuberculosis (TB) cases treated at the Baltimore City Health Department between 2008 and 2013.

METHODS

We categorised patients as having 'only PTB' (infection in the lung parenchyma), 'EPTB/PTB' (infection in the lung and an additional site), and 'only EPTB' (infection not involving the lung). Pearson's chi-squared tests were used to evaluate categorical variables and compare clinical and demographic differences between only PTB, only EPTB, and EPTB/PTB patients. Student t-tests and one-way analysis of variance tests were utilised to assess continuous variables and to compare treatment differences.

RESULTS

One hundred and sixty-three patients were treated for TB; 39.3% had some form of EPTB (either EPTB/PTB or only EPTB). There was no difference found between EPTB, PTB, and EPTB/PTB patients with respect to HIV status, gender, race, foreign-born status, or mean age. Patients with only EPTB were less likely than patients with some form of PTB (only PTB or EPTB/PTB) to present with cough (30.4% vs 61.5%; P < 0.001), night sweats (10.9% vs 39.3%; P < 0.001), and weight loss (28.3% vs 47.9%; P = 0.023). Patients with some form of EPTB were also more likely to be hospitalised postdiagnosis compared to patients with only PTB (39.1% vs 20.2%; P = 0.009), and to have longer mean durations of treatment (37.9 weeks [SD = 11.1] vs 31.8 weeks [SD = 8.1]; P < 0.001).

CONCLUSIONS

EPTB patients present with atypical symptoms, undergo prolonged treatment, and experience increased hospitalisations. In order to improve diagnostic algorithms and treatment modalities, EPTB must be further characterised.

Assessment of the efficacy of drug transdermal delivery by electro-phonophoresis in treating tuberculous lymphadenitis

Electro-phonophoresis (EP) has been used in various clinical fields. The objective of present study is to evaluate the skin permeability of isoniazid (INH) and rifampicin (RIF) in patients with tuberculous lymphadenitis with the aid of EP to validate the clinical applications of this transdermal delivery system for the treatment of superficial extrapulmonary tuberculosis. INH and RIF solutions were delivered transdermally, with or without EP, in the surrounding tissue of the lesion for 0.5 h. Local pyogenic fluids or necrotic tissue samples from the infection sites in patients were collected at 1 h after dosing. Drug concentrations in samples were evaluated by high performance liquid chromatography. The median INH and RIF intra-lesional concentrations were 0.365 (interquartile range [IQR] 0.185-1.775) μg/mL and 1.231 (IQR 0.304-1.836) μg/mL in oral group; 2.964 (IQR 0.193-7.325) μg/mL and 2.646 (IQR 1.211-3.753) μg/mL in INH- and RIF-transdermal plus EP group. Drug concentrations in the local sites of patients receiving INH or RIF through EP transdermal delivery were statistically higher than those observed in patients only taking INH and RIF orally. However, this enhancement was not observed in the transdermal delivery of INH or RIF without EP in contrast to the oral administrations of drugs. EP can effectively enhance the skin permeability of INH and RIF in patients with tuberculous lymphadenitis. The increase in drug concentrations in the lesions could help eradication of the germs; shorten the treatment course and increase the cure rate of patients with tuberculous lymphadenitis.

Tuberculous Pericarditis is Multibacillary and Bacterial Burden Drives High Mortality

BACKGROUND

Tuberculous pericarditis is considered to be a paucibacillary process; the large pericardial fluid accumulation is attributed to an inflammatory response to tuberculoproteins. Mortality rates are high. We investigated the role of clinical and microbial factors predictive of tuberculous pericarditis mortality using the artificial intelligence algorithm termed classification and regression tree (CART) analysis.

METHODS

Patients were prospectively enrolled and followed in the Investigation of the Management of Pericarditis (IMPI) registry. Clinical and laboratory data of 70 patients with confirmed tuberculous pericarditis, including time-to-positive (TTP) cultures from pericardial fluid, were extracted and analyzed for mortality outcomes using CART. TTP was translated to log10 colony forming units (CFUs) per mL, and compared to that obtained from sputum in some of our patients.

FINDINGS

Seventy patients with proven tuberculous pericarditis were enrolled. The median patient age was 35 (range: 20-71) years. The median, follow up was for 11.97 (range: 0·03-74.73) months. The median TTP for pericardial fluid cultures was 22 (range: 4-58) days or 3.91(range: 0·5-8·96) log10CFU/mL, which overlapped with the range of 3.24-7.42 log10CFU/mL encountered in sputum, a multi-bacillary disease. The overall mortality rate was 1.43 per 100 person-months. CART identified follow-up duration of 5·23 months on directly observed therapy, a CD4 + count of ≤ 199.5/mL, and TTP ≤ 14 days (bacillary load ≥ 5.53 log10 CFU/mL) as predictive of mortality. TTP interacted with follow-up duration in a non-linear fashion.

INTERPRETATION

Patients with culture confirmed tuberculous pericarditis have a high bacillary burden, and this bacterial burden drives mortality. Thus proven tuberculosis pericarditis is not a paucibacillary disease. Moreover, the severe immunosuppression suggests limited inflammation. There is a need for the design of a highly bactericidal regimen for this condition.