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Peng L, Ma W, Zhong L, Yang J, Wu H, Zhu L, Huang X, Yang R, Li B, Ma W, Wu X, Song J, Luo S, Bao F, Liu A. Diagnostic Accuracy of Mycobacterium tuberculosis Antigen-Based Skin Tests (TBSTs) for Tuberculosis Infection Compared with TST and IGRA: A Network Meta-Analysis. Pathogens 2024; 13:1050. [PMID: 39770310 PMCID: PMC11728611 DOI: 10.3390/pathogens13121050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Revised: 11/15/2024] [Accepted: 11/25/2024] [Indexed: 01/16/2025] Open
Abstract
The aim of this study was to evaluate the diagnostic accuracy of the IGRA, TST, and TBST by combining diagnostic test accuracy (DTA) analysis and network meta-analysis (NMA) to increase the reliability and accuracy of diagnostic methods and promote the eradication of TB. An electronic search of the PubMed, Embase, and Cochrane databases was conducted, from the date of establishment to September 30, 2024. Data were synthesized with frequentist random-effects network meta-analyses, a single-group rate meta-analysis algorithm, and a bivariate mixed-effects logistic regression model. Summarized receiver operating characteristic curves and Fagan nomograms were used to assess diagnostic accuracy and clinical utility. Deeks' funnel plots and the Quality Assessment of Diagnostic Accuracy Studies 2 tools were used to assess publication bias and risk of bias. Sources of heterogeneity were investigated using subgroup analyses. Forty-nine studies were identified. The diagnostic performance of the three diagnostic methods for TB infection is summarized as follows: the pooled sensitivity was 77.9% (95% confidence interval [CI], 0.69-0.856), and the pooled specificity was 80.3% (95% CI, 0.75-0.86). The sensitivity and specificity of the IGRA were 82.1% (95% CI, 0.78-0.86) and 81.1% (95% CI, 0.75-0.86), respectively, both higher than the TST. However, the TBST exhibited the highest specificity, at 98.5% (95% CI, 0.96-1.00), with a sensitivity of 78.7% (95% CI, 0.68-0.88), which was between that of the IGRA and TST. Subgroup analysis found that population categories and reference standards, among other factors, may be attributed to heterogeneity. In addition, the TST and IGRA add-on TBST can significantly improve diagnostic accuracy. In our study, the IGRA showed higher sensitivity, whereas the TBST showed higher specificity. Interestingly, under certain conditions, TST add-on TBST and IGRA add-on TBST showed better accuracy than TST and IGRA alone and could provide more effective guidance for clinical practice (PROSPERO CRD42023420136).
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Affiliation(s)
- Li Peng
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Weijie Ma
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Lei Zhong
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Jiaru Yang
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Hanxin Wu
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Liangyu Zhu
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Xun Huang
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Rui Yang
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Bingxue Li
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Weijiang Ma
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Xinya Wu
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Jieqin Song
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Suyi Luo
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
| | - Fukai Bao
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
- Research Center, Baoshan People’s Hospital, Baoshan 678000, China
- Yunnan Provincial Key Laboratory of Public Health and Biosafety, School of Public Health, Kunming Medical University, Kunming 650500, China
| | - Aihua Liu
- Yunnan Province Key Laboratory of Children’s Major Diseases Research, School of Basic Medical Sciences, Kunming Medical University, Kunming 650500, China; (L.P.); (W.M.); (L.Z.); (J.Y.); (H.W.); (L.Z.); (X.H.); (R.Y.); (B.L.); (W.M.); (X.W.); (J.S.); (S.L.)
- Yunnan Provincial Key Laboratory of Public Health and Biosafety, School of Public Health, Kunming Medical University, Kunming 650500, China
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Hirabayashi R, Nakayama H, Yahaba M, Yamanashi H, Kawasaki T. Utility of interferon-gamma releasing assay for the diagnosis of active tuberculosis in children: A systematic review and meta-analysis. J Infect Chemother 2024; 30:516-525. [PMID: 38104794 DOI: 10.1016/j.jiac.2023.12.007] [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: 09/27/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION The accurate diagnosis of tuberculosis (TB) in children is essential for its effective management and control. Reliable diagnostic tools that are currently available for identifying TB infection include the in vivo tuberculosis skin test (TST) and ex vivo interferon-gamma release assays (IGRAs). This systematic review and meta-analysis aimed to evaluate the diagnostic accuracy of IGRAs in children. METHODS Of the 768 screened studies, 47 met the eligibility criteria. Data from 9065 patients, including 1086 (12.0 %) with confirmed TB, were included in the analysis. The overall quality of the included studies, assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool, was unclear. RESULTS The calculated pooled sensitivity and specificity of IGRAs in children were 0.85 (95 % confidence interval [CI]: 0.79-0.89) and 0.94 (95 % CI: 0.88-0.97), respectively. Subpopulation analysis revealed that the sensitivities and specificities were as follows: QuantiFERON tests: 0.83 (95 % CI: 0.74-0.89) and 0.93 (95 % CI: 0.87-0.96), T-SPOT: 0.87 (95 % CI: 0.79-0.91) and 0.99 (95 % CI: 0.85-1.00), IGRAs in children under 15 years: 0.77 (95 % CI: 0.43-0.94) and 0.96 (95 % CI: 0.84-0.97), and IGRAs in children under 5 years: 0.85 (95 % CI: 0.52-0.97) and 0.94 (95 % CI: 0.90-0.99), respectively. CONCLUSIONS This study demonstrated that the sensitivity and specificity of the IGRAs in children were moderate and high, respectively. Therefore, the IGRAs may be useful for detecting TB infection in children. CLINICAL TRIAL REGISTRATION The review protocol was prospectively registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000046737).
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Affiliation(s)
- Ryosuke Hirabayashi
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Japan
| | - Haruo Nakayama
- Department of Neurosurgery, Toho University Ohasi Medical Center, Japan
| | - Misuzu Yahaba
- Division of Infection Control, Chiba University Hospital, Japan
| | - Hirotomo Yamanashi
- Department of General Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Takeshi Kawasaki
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan.
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Pasqualini C, Cohen L, Le Roux E, Caseris M, Faye A. Tuberculosis in 0-5-year-old children following TB contact investigations: a retrospective study in a low burden setting. Front Pediatr 2023; 11:1145191. [PMID: 37404556 PMCID: PMC10315530 DOI: 10.3389/fped.2023.1145191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 05/30/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction We assessed the risk of tuberculosis (TB), the management and the outcomes of 0-5-year-old children after TB contact investigations in a low-burden setting. Method All 0-5-year-old children who attended the TB clinic of Robert Debre Hospital, Paris, France, for a TB contact investigation between June 2016 and December 2019 were included in this retrospective study. The risk factors for TB were assessed using univariate and multivariate analyses. Results A total of 261 children were included. Forty-six (18%) had TB, including 37 latent tuberculosis infections (LTBIs) and 9 active TB diseases. The prevalence of TB was 21% among high-risk contacts, i.e., household or close contacts and regular or casual contacts. There was no TB among intermediate- or low-risk contacts (0/42). Living under the same roof with (OR: 19.8; 95% CI: 2.6-153), the BCG vaccine (OR: 3.2; 95% CI: 1.2-8.3), contact duration >40 h (OR: 7.6; 95% CI: 2.3-25.3) and sleeping in the room of the index case (OR: 3.9; 95% CI: 1.3-11.7) were independently associated with TB. The BCG vaccine was no longer associated when the analysis was restricted to interferon gamma release assay results. Among children without initial LTBI, antibiotic prophylaxis was not prescribed for 2-5-year-old children or for 32/36 (89%) of 0-2-year-old children who had intermediate- or low-risk contact. Overall, none of these children experienced TB. Conclusion In our low prevalence setting, the risk of TB in 0-5-year-old children following a household or close contact was high. Further studies are needed to better assess prophylaxis recommendations in intermediate or low risk contact.
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Affiliation(s)
- Cassandre Pasqualini
- Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale et Maladies Infectieuses, Hôpital Robert Debré, Paris, France
| | - Laure Cohen
- Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale et Maladies Infectieuses, Hôpital Robert Debré, Paris, France
| | - Enora Le Roux
- AP-HP, Nord-Université Paris Cité, Hôpital Universitaire Robert Debré, Unité d'Épidémiologie Clinique, Inserm, Paris, France
- ECEVE, Inserm, Paris, France
| | - Marion Caseris
- Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale et Maladies Infectieuses, Hôpital Robert Debré, Paris, France
| | - Albert Faye
- Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale et Maladies Infectieuses, Hôpital Robert Debré, Paris, France
- ECEVE, Inserm, Paris, France
- Université Paris Cité, Paris, France
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Abstract
Tuberculosis (TB) remains an important problem among children in the United States and throughout the world. There is no diagnostic reference standard for latent tuberculosis infection (also referred to as tuberculosis infection [TBI]). The tuberculin skin test (TST) has many limitations, including difficulty in administration and interpretation, the need for a return visit by the patient, and false-positive results caused by cross-reaction with Mycobacterium bovis-bacille Calmette-Guerin vaccines and many nontuberculous mycobacteria. Interferon-gamma release assays (IGRAs) are blood tests that use antigens specific for M tuberculosis; as a result, IGRAs yield fewer false-positive results than the TST. Both IGRAs and the TST have reduced sensitivity in immunocompromised children, including children with severe TB disease. Both methods have high positive predictive value when applied to children with risk factors for TBI, especially recent contact with a person who has TB disease. The advantages of using IGRAs and diminished experience with the placement and interpretation of the TST favor expanded use of IGRAs in children in the United States. There are now several effective and safe regimens for the treatment of TBI in children. For improved adherence to therapy, the 3 rifamycin-based regimens are preferred because of their short duration. Daily isoniazid can be used if there is intolerance or drug interactions with rifamycins. A TB specialist should be involved when there are questions regarding testing interpretation, selection of an appropriate treatment regimen, or management of adverse effects.
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Affiliation(s)
- Dawn Nolt
- Department of Pediatrics, Division of Infectious Diseases, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey R Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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Owens DR, Medalla CM, Brown KN, Wijewardena K, Thomas CP, Iro MA, Jones CE, Faust SN, Patel SV. Problem-solving in clinical practice: Persisting respiratory distress in a premature infant. Arch Dis Child Educ Pract Ed 2021; 106:239-243. [PMID: 33077533 DOI: 10.1136/archdischild-2019-317757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 07/12/2020] [Accepted: 08/28/2020] [Indexed: 11/03/2022]
Abstract
The deterioration of a previously stable preterm infant is a common scenario on the neonatal unit. The the most common bacterial causes of deterioration are nosocomial infections, such as coagulase-negative Staphylococcus and Staphylococcus aureus Non-infective conditions such as pulmonary haemorrhage, anaemia of prematurity and necrotising enterocolitis may also cause preterm infants to deteriorate. This case chronicles the unusual diagnostic journey of an infant born at 27+1 weeks who deteriorated at 26 days of life and did not respond to antimicrobial therapy as anticipated.
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Affiliation(s)
- Daniel R Owens
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | - Kelly N Brown
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kishani Wijewardena
- Department of Child Health, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - Claire P Thomas
- Department of Clinical Microbiology/Infection, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - Mildred A Iro
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK.,Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Christine E Jones
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Sanjay Valabh Patel
- Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Rahman S, Irfan M, Siddiqui MAR. Role of interferon gamma release assay in the diagnosis and management of Mycobacterium tuberculosis-associated uveitis: a review. BMJ Open Ophthalmol 2021; 6:e000663. [PMID: 34046524 PMCID: PMC8118067 DOI: 10.1136/bmjophth-2020-000663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 11/23/2022] Open
Abstract
Tuberculosis (TB)-associated uveitis is a common cause of infectious uveitis in the developing world. Diagnosis of TB uveitis remains a challenge. The role of interferon gamma release assays (IGRAs) is uncertain. Herein we summarise the available literature on the utility of IGRAs in the diagnosis and management of TB uveitis. We searched PubMed database from 1 August 2010 to 31 July 2020 using the following keywords alone and in combination: 'interferon-gamma release assay', 'QuantiFERON', 'T-SPOT.TB', 'TB uveitis', 'serpiginous like choroiditis', 'tuberculoma', 'TB vasculitis', 'TB panuveitis' and 'ocular tuberculosis'. Data from 58 relevant studies were collated. The review is focused on currently marketed versions of IGRA tests: QuantiFERON-TB Gold In-Tube assay, QuantiFERON-TB Gold Plus assay (QFT-Plus) and T-SPOT.TB. We found limited evidence regarding the diagnostic utility of IGRA in patients with uveitis. No study was identified evaluating the newer QFT test-the QFT-Plus-in patients with uveitis. Similarly, there is lack of data directly comparing QFT-Plus with T-SPOT.TB specifically for the diagnosis of TB uveitis.
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Affiliation(s)
- Samra Rahman
- Karachi Medical and Dental College, Karachi, Pakistan
| | - Muhammad Irfan
- Section of Pulmonology, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - M A Rehman Siddiqui
- Section of Ophthalmology, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Evaluation of Interleukin-2 to Detect Active and Latent Tuberculosis among Household Contacts of Pulmonary Tuberculosis Cases. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2021. [DOI: 10.5812/pedinfect.109398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The interferon-gamma release assays (IGRAs) are the most important diagnostic approach to Mycobacterium tuberculosis infection diagnosis. However, they cannot discriminate between latent tuberculosis infection (LTBI) and active tuberculosis (TB). Some recent studies suggested that interleukin-2 (IL-2) response to M. tuberculosis could be utilized as a potential biomarker to discriminate active disease from LTBI. Objectives: The current study aimed at evaluating the potential role of IL-2 to detect both active TB and LTBI among household contacts of patients with pulmonary TB in two TB-endemic regions of Iran. Methods: A total of 650 household contacts of patients with TB were invited to participate in the current study. All subjects were diagnosed on extensive clinical evaluation of active TB and LTBI based on clinical manifestations and laboratory findings. The IGRA test was performed using QuantiFERON®-TB Gold Plus. The serum level of IL-2 was measured using the ELISA Development Kit. Results: A total of 237 household contacts entered the final analysis, including 132 patients with LTBI and three with active TB. In addition, 14 subjects were included as TB controls and 102 as TB-uninfected controls. The serum level of IL-2 was significantly higher in active TB and LTBI patients than TB-uninfected controls. The ROC curve was plotted between active TB and LTBI, revealing that the cutoff point of 25.5 pg/mL identifies the active form with 88.24% sensitivity and 36.36% specificity. Conclusions: The current study indicated that the IL-2 assay could not discriminate between active TB and LTBI with acceptable sensitivity.
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Takwoingi Y, Whitworth H, Rees-Roberts M, Badhan A, Partlett C, Green N, Boakye A, Lambie H, Marongiu L, Jit M, White P, Deeks JJ, Kon OM, Lalvani A. Interferon gamma release assays for Diagnostic Evaluation of Active tuberculosis (IDEA): test accuracy study and economic evaluation. Health Technol Assess 2020; 23:1-152. [PMID: 31138395 DOI: 10.3310/hta23230] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Interferon gamma release assays (IGRAs) are blood tests recommended for the diagnosis of tuberculosis (TB) infection. There is currently uncertainty about the role and clinical utility of IGRAs in the diagnostic workup of suspected active TB in routine NHS clinical practice. OBJECTIVES To compare the diagnostic accuracy and cost-effectiveness of T-SPOT.TB ® (Oxford Immunotec, Abingdon, UK) and QuantiFERON® TB GOLD In-Tube (Cellestis, Carnegie, VIC, Australia) for diagnosis of suspected active TB and to estimate the diagnostic accuracy of second-generation IGRAs. DESIGN Prospective within-patient comparative diagnostic accuracy study. SETTING Secondary care. PARTICIPANTS Adults (aged ≥ 16 years) presenting as inpatients or outpatients at 12 NHS hospital trusts in London, Slough, Oxford, Leicester and Birmingham with suspected active TB. INTERVENTIONS The index tests [T-SPOT.TB and QuantiFERON GOLD In-Tube (QFT-GIT)] and new enzyme-linked immunospot assays utilising novel Mycobacterium tuberculosis antigens (Rv3615c, Rv2654, Rv3879c and Rv3873) were verified against a composite reference standard applied by a panel of clinical experts blinded to IGRA results. MAIN OUTCOME MEASURES Sensitivity, specificity, predictive values and likelihood ratios were calculated to determine diagnostic accuracy. A decision tree model was developed to calculate the incremental costs and incremental health utilities [quality-adjusted life-years (QALYs)] of changing from current practice to using an IGRA as an initial rule-out test. RESULTS A total of 363 patients had active TB (culture-confirmed and highly probable TB cases), 439 had no active TB and 43 had an indeterminate final diagnosis. Comparing T-SPOT.TB and QFT-GIT, the sensitivities [95% confidence interval (CI)] were 82.3% (95% CI 77.7% to 85.9%) and 67.3% (95% CI 62.1% to 72.2%), respectively, whereas specificities were 82.6% (95% CI 78.6% to 86.1%) and 80.4% (95% CI 76.1% to 84.1%), respectively. T-SPOT.TB was more sensitive than QFT-GIT (relative sensitivity 1.22, 95% CI 1.14 to 1.31; p < 0.001), but the specificities were similar (relative specificity 1.02, 95% CI 0.97 to 1.08; p = 0.3). For both IGRAs the sensitivity was lower and the specificity was higher for human immunodeficiency virus (HIV)-positive than for HIV-negative patients. The most promising novel antigen was Rv3615c. The added value of Rv3615c to T-SPOT.TB was a 9% (95% CI 5% to 12%) relative increase in sensitivity at the expense of specificity, which had a relative decrease of 7% (95% CI 4% to 10%). The use of current IGRA tests for ruling out active TB is unlikely to be considered cost-effective if a QALY was valued at £20,000 or £30,000. For T-SPOT.TB, the probability of being cost-effective for a willingness to pay of £20,000/QALY was 26% and 21%, when patients with indeterminate test results were excluded or included, respectively. In comparison, the QFT-GIT probabilities were 8% and 6%. Although the use of IGRAs is cost saving, the health detriment is large owing to delay in diagnosing active TB, leading to prolonged illness. There was substantial between-patient variation in the tests used in the diagnostic pathway. LIMITATIONS The recruitment target for the HIV co-infected population was not achieved. CONCLUSIONS Although T-SPOT.TB was more sensitive than QFT-GIT for the diagnosis of active TB, the tests are insufficiently sensitive for ruling out active TB in routine clinical practice in the UK. Novel assays offer some promise. FUTURE WORK The novel assays require evaluation in distinct clinical settings and in immunosuppressed patient groups. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and the NIHR Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK.
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Affiliation(s)
- Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Hilary Whitworth
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Melanie Rees-Roberts
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
| | - Amarjit Badhan
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
| | | | - Nathan Green
- NIHR Health Protection Research Unit in Modelling Methodology, Imperial College London, London, UK.,Medical Research Council (MRC) Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK.,Department of Infectious Disease Epidemiology, Imperial College London, London, UK.,Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Aime Boakye
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
| | - Heather Lambie
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
| | - Luigi Marongiu
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
| | - Mark Jit
- Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter White
- NIHR Health Protection Research Unit in Modelling Methodology, Imperial College London, London, UK.,Medical Research Council (MRC) Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK.,Department of Infectious Disease Epidemiology, Imperial College London, London, UK.,Modelling and Economics Unit, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Onn Min Kon
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK.,St Mary's Hospital, Imperial College Healthcare Trust, London, UK
| | - Ajit Lalvani
- Tuberculosis Research Centre, National Heart and Lung Institute, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
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9
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Meier NR, Volken T, Geiger M, Heininger U, Tebruegge M, Ritz N. Risk Factors for Indeterminate Interferon-Gamma Release Assay for the Diagnosis of Tuberculosis in Children-A Systematic Review and Meta-Analysis. Front Pediatr 2019; 7:208. [PMID: 31192175 PMCID: PMC6548884 DOI: 10.3389/fped.2019.00208] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 05/08/2019] [Indexed: 12/26/2022] Open
Abstract
Background: Interferon-gamma release assays (IGRA) are well-established immunodiagnostic tests for tuberculosis (TB) in adults. In children these tests are associated with higher rates of false-negative and indeterminate results. Age is presumed to be one factor influencing cytokine release and therefore test performance. The aim of this study was to systematically review factors associated with indeterminate IGRA results in pediatric patients. Methods: Systematic literature review guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) searching PubMed, EMBASE, and Web of Science. Studies reporting results of at least one commercially available IGRA (QuantiFERON-TB, T-SPOT.TB) in pediatric patient groups were included. Random effects meta-analysis was used to assess proportions of indeterminate IGRA results. Heterogeneity was assessed using the I2 value. Risk differences were calculated for studies comparing QuantiFERON-TB and T-SPOT.TB in the same study. Meta-regression was used to further explore the influence of study level variables on heterogeneity. Results: Of 1,293 articles screened, 133 studies were included in the final analysis. These assessed QuantiFERON-TB only in 77.4% (103/133), QuantiFERON-TB and T-SPOT.TB in 15.8% (21/133), and T-SPOT.TB only in 6.8% (9/133) resulting in 155 datasets including 107,418 participants. Overall 4% of IGRA results were indeterminate, and T-SPOT.TB (0.03, 95% CI 0.02-0.05) and QuantiFERON-TB assays (0.05, 95% CI 0.04-0.06) showed similar proportions of indeterminate results; pooled risk difference was-0.01 (95% CI -0.03 to 0.00). Significant differences with lower proportions of indeterminate assays with T-SPOT.TB compared to QuantiFERON-TB were only seen in subgroup analyses of studies performed in Africa and in non-HIV-infected immunocompromised patients. Meta-regression confirmed lower proportions of indeterminate results for T-SPOT.TB compared to QuantiFERON-TB only among studies that reported results from non-HIV-infected immunocompromised patients (p < 0.001). Conclusion: On average indeterminate IGRA results occur in 1 in 25 tests performed. Overall, there was no difference in the proportion of indeterminate results between both commercial assays. However, our findings suggest that in patients in Africa and/or patients with immunocompromising conditions other than HIV infection the T-SPOT.TB assay appears to produce fewer indeterminate results.
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Affiliation(s)
- Noëmi R Meier
- Mycobacterial Research Laboratory, University of Basel Children's Hospital, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Thomas Volken
- School of Health Professions, Zürich University of Applied Sciences, Winterthur, Switzerland
| | - Marc Geiger
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Ulrich Heininger
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Paediatric Infectious Diseases and Vaccinology Unit, University of Basel Children's Hospital, Basel, Switzerland
| | - Marc Tebruegge
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom.,Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.,Royal Children's Hospital Melbourne, Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Nicole Ritz
- Mycobacterial Research Laboratory, University of Basel Children's Hospital, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland.,Paediatric Infectious Diseases and Vaccinology Unit, University of Basel Children's Hospital, Basel, Switzerland.,Royal Children's Hospital Melbourne, Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
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10
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Kay AW, Islam SM, Wendorf K, Westenhouse J, Barry PM. Interferon-γ Release Assay Performance for Tuberculosis in Childhood. Pediatrics 2018; 141:peds.2017-3918. [PMID: 29728429 DOI: 10.1542/peds.2017-3918] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Interferon-γ release assays (IGRAs) are important adjunctive tests for diagnosing tuberculosis (TB) disease in children. METHODS We analyzed California TB registry data for patients ≤18 years with laboratory-confirmed TB disease during 2010-2015 to identify case characteristics associated with test selection and performance and measure IGRA sensitivity. RESULTS In total, 778 cases of TB were reported; 360 were laboratory confirmed. Indeterminate IGRAs were associated with being <1 year old (prevalence rate ratio 9.23; 95% confidence interval 2.87 to 29.8) and having central nervous system disease (prevalence rate ratio 2.69; 95% confidence interval 1.06 to 6.86) on multivariable analysis. Ninety-five children had both an IGRA and tuberculin skin test (TST) performed. Among those, the sensitivity of IGRA in 5- to 18-year-olds was 96% (66 out of 69) vs 83% (57 out of 69) for TST (P = .01); IGRA sensitivity compared with TST in children ages 2 to 4 was 91% (10 out of 11) vs 91% (10 out of 11) (P > .99), and the sensitivity compared with TST in children aged <2 years was 80% (12 out of 15) vs 87% (13 out of 15) (P > .99). CONCLUSIONS This is the largest North American analysis of IGRA use and performance among children with TB disease. In children <5 years old, IGRA sensitivity is similar to TST, but sensitivity of both tests are reduced in children <2 years old. Indeterminate results are higher in children <1 year old and in central nervous system disease. In children ≥5 years old with laboratory-confirmed TB, IGRA has greater sensitivity than TST and should be considered the preferred immunodiagnostic test..
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Affiliation(s)
- Alexander W Kay
- California Department of Public Health, Richmond, California; and
| | - Shamim M Islam
- University at Buffalo, State University of New York, Buffalo, New York
| | - Kristen Wendorf
- California Department of Public Health, Richmond, California; and
| | | | - Pennan M Barry
- California Department of Public Health, Richmond, California; and
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11
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van de Loo K, Balzer S, MacKenzie CR, Boemers TM, Ortmann M, Schaper J, Borkhardt A, Laws HJ, Kuhlen M. Lymphnode tuberculosis in a 4-year-old boy with relapsed ganglioneuroblastoma: a case report. BMC Infect Dis 2018; 18:105. [PMID: 29506484 PMCID: PMC5839039 DOI: 10.1186/s12879-018-3016-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 02/28/2018] [Indexed: 11/28/2022] Open
Abstract
Background Mycobacterium tuberculosis (M. tuberculosis) disease is a generally well-known problem among immunocompromised adults and children. In pediatric oncology, only few cases of M. tuberculosis disease are reported so far. Case presentation We report a case of concomitant lymphnode tuberculosis in a 4-year-old German boy with relapsed ganglioneuroblastoma. 18 months after the initial diagnosis, relapse with new paravertebral lesions and new lesions in the left lower lobe of the lung and in the perihilar lymphnodes suspicious of metastases of the ganglioneuroblastoma were detected. While relapse in the tumor was confirmed, unexpectedly, pathologic examination revealed morphological diagnosis of lymphnode tuberculosis. The boy was of German background without previous history of tuberculosis exposure. Both, antituberculostatic and relapse treatment were immediately initiated. Three months on, MRI revealed regressive findings in the lung and lymphnodes and partial response in the tumor. The patient underwent second MiBG therapy and haploidentical stem cell transplantation. Conclusion The diagnosis of lymphnode tuberculosis in a 4-year-old German boy with relapsed ganglioneuroblastoma was only made by chance, but most likely saved his life. Pediatric oncologist should be aware of tuberculosis as the incidence might increase over time and the timely diagnosis of a potentially preventable M. tuberculosis disease is irreplaceable. Further studies are needed to explore the incidence of M. tuberculosis infections and the value of IGRA, testing for latent tuberculosis infection prior to chemotherapy in children with underlying malignancies.
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Affiliation(s)
- Karoline van de Loo
- Department of Paediatric Oncology, Medical Faculty, Haematology and Clinical Immunology, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
| | - Stefan Balzer
- Department of Paediatric Oncology, Medical Faculty, Haematology and Clinical Immunology, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Colin R MacKenzie
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital of Duesseldorf, Heinrich-Heine University, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Thomas M Boemers
- Department of Pediatric Surgery and Pediatric Urology, Children's Hospital, Amsterdamer Str. 59, 50735, Cologne, Germany
| | - Monika Ortmann
- Institute of Pathology, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Jörg Schaper
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Arndt Borkhardt
- Department of Paediatric Oncology, Medical Faculty, Haematology and Clinical Immunology, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Hans-Jürgen Laws
- Department of Paediatric Oncology, Medical Faculty, Haematology and Clinical Immunology, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Michaela Kuhlen
- Department of Paediatric Oncology, Medical Faculty, Haematology and Clinical Immunology, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
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12
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Chang PC, Wang PH, Chen KT. Use of the QuantiFERON-TB Gold In-Tube Test in the Diagnosis and Monitoring of Treatment Efficacy in Active Pulmonary Tuberculosis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14030236. [PMID: 28264462 PMCID: PMC5369072 DOI: 10.3390/ijerph14030236] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 02/09/2017] [Accepted: 02/23/2017] [Indexed: 12/17/2022]
Abstract
The value of QuantiFERON in the diagnosis of tuberculosis disease and in the monitoring of the response to anti-tuberculosis treatment is unclear. The aims of this study were to evaluate the accuracy of the QuantiFERON-TB Gold In-Tube (QFT-GIT) test in the diagnosis of tuberculosis and in the monitoring of the response to anti-tuberculosis treatment in patients with active pulmonary tuberculosis (PTB). Between January 2013 and December 2015, 133 cases with active PTB and 133 controls with no mycobacterial infection, matched by age (within 3 years) and by the week that they visited Tainan Chest Hospital, were enrolled in the study. Serial testing by QFT-GIT at baseline and after 2 and 6 months of treatment was performed. At these time points, a comparison of the performance of QFT-GIT with that of sputum culture status among study subjects was conducted. Compared to baseline, 116 (87.2%) cases showed a decreased response, whereas 17 (12.8%) showed persistent or stronger interferon-gamma (IFN-γ) responses at 2 months. PTB patients IFN-γ responses declined significantly from baseline to 2 months (median, 6.32 vs. 4.12; p < 0.005). The sensitivity values of the QFT-GIT test for the detection of pulmonary tuberculosis at cut-off points of 0.35 IU/mL, 0.20 IU/mL, and 0.10 IU/mL were 74.4%, 78.2%, and 80.5%, respectively. The specificity values at cut-off points of 0.35 IU/mL, 0.20 IU/mL, and 0.10 IU/mL were 66.2%, 63.9%, and 57.1%, respectively. Our results support the QFT-GIT assay as a potential tool for diagnosing tuberculosis and for monitoring the efficacy of anti-tuberculosis treatment.
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Affiliation(s)
- Ping-Chin Chang
- Division of Infectious Diseases, Department of Internal Medicine, Chi-Mei Medical Center, Liouying, Tainan 736, Taiwan.
| | - Pin-Hui Wang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan.
| | - Kow-Tong Chen
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan.
- Department of Occupational Medicine, Tainan Municipal Hospital, Tainan 701, Taiwan.
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13
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Sun L, Li JQ, Ren N, Qi H, Dong F, Xiao J, Xu F, Jiao WW, Shen C, Song WQ, Shen AD. Utility of Novel Plasma Metabolic Markers in the Diagnosis of Pediatric Tuberculosis: A Classification and Regression Tree Analysis Approach. J Proteome Res 2016; 15:3118-25. [PMID: 27451809 DOI: 10.1021/acs.jproteome.6b00228] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Although tuberculosis (TB) has been the greatest killer due to a single infectious disease, pediatric TB is still hard to diagnose because of the lack of sensitive biomarkers. Metabolomics is increasingly being applied in infectious diseases. But little is known regarding metabolic biomarkers in children with TB. A combination of a NMR-based plasma metabolic method and classification and regression tree (CART) analysis was used to provide a broader range of applications in TB diagnosis in our study. Plasma samples obtained from 28 active TB children and 37 non-TB controls (including 21 RTIs and 16 healthy children) were analyzed by an orthogonal partial least-squares discriminant analysis (OPLS-DA) model, and 17 metabolites were identified that can separate children with TB from non-TB controls. CART analysis was then used to choose 3 of the markers, l-valine, pyruvic acid, and betaine, with the least error. The sensitivity, specificity, and area under the curve (AUC) of the 3 metabolites is 85.7% (24/28, 95% CI, 66.4%, 95.3%), 94.6% (35/37, 95% CI, 80.5%, 99.1%), and 0.984(95% CI, 0.917, 1.000), respectively. The 3 metabolites demonstrated sensitivity of 82.4% (14/17, 95% CI, 55.8%, 95.3%) and specificity of 83.9% (26/31, 95% CI, 65.5%, 93.9%), respectively, in 48 blinded subjects in an independent cohort. Taken together, the novel plasma metabolites are potentially useful for diagnosis of pediatric TB and would provide insights into the disease mechanism.
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Affiliation(s)
- Lin Sun
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - Jie-Qiong Li
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - Na Ren
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - Hui Qi
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - Fang Dong
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - Jing Xiao
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - Fang Xu
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - Wei-Wei Jiao
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - Chen Shen
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - Wen-Qi Song
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
| | - A-Dong Shen
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Key Discipline of Pediatrics (Capital Medical University), Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University , 100045 Beijing, People's Republic of China
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