Challenges and perspectives in the diagnosis of extrapulmonary tuberculosis

Next-Gen Dual Transcriptomics for Adult Extrapulmonary Tuberculosis Biomarkers and Host-Pathogen Interplay in Human Cells: A Strategic Review

Tuberculosis (TB) is a major public health concern that results in significant morbidity and mortality, particularly in middle- to low-income countries. Extra-pulmonary tuberculosis (EPTB) in adults is a form of TB that affects organs other than the lungs and is challenging to diagnose and treat due to a lack of accurate early diagnostic markers and inadequate knowledge of host immunity. Next-generation sequencing-based approaches have shown potential for identifying diagnostic biomarkers and host immune responses related to EPTB. This strategic review discusses on the significance using primary human cells and cell lines for in vitro transcriptomic studies on common forms of EPTB, such as lymph node TB, brain TB, bone TB, and endometrial TB to derive potential insights. While organoids have shown promise as a model system, primary cell lines still remain a valuable tool for studying host-pathogen interplay due to their conserved immune system, non-iPSC origin, and lack of heterogeneity in cell population. This review outlines a basic workflow for researchers interested in performing transcriptomics studies in EPTB, and also discusses the potential of cell-line based dual RNA-Seq technology for deciphering comprehensive transcriptomic signatures, host-pathogen interplay, and biomarkers from the host and Mycobacterium tuberculosis. Thus, emphasizing the implementation of this technique which can significantly contribute to the global anti-TB effort and advance our understanding of EPTB.

Graphical Abstract

Multidrug-resistant tuberculous orchiepididymitis: a brief case report

Tuberculosis (TB) is one of the leading causes of death by infectious diseases worldwide. Multidrug-resistant tuberculosis is a growing problem, especially in countries with high TB prevalence. Although the lungs are the organs most frequently affected by this disease, Mycobacterium tuberculosis can harm any organ, including the urogenital tract, causing extrapulmonary tuberculosis, which leads to a challenging diagnosis and consequent treatment delays. In this article, we present a case of orchiepididymitis caused by multidrug-resistant TB (MDR-TB) with a significantly delayed diagnosis, the proposed treatment according to the resistance profile, and the clinical outcomes.

Isolated soft tissue tuberculosis: a case report and literature review

Soft tissue tuberculosis is a rare extrapulmonary form of tuberculosis with limited experience in diagnosis and treatment. Soft tissue tuberculosis is an extrapulmonary infection with atypical clinical symptoms that can be easily misdiagnosed. In this article, we report a case of a female patient with isolated soft tissue tuberculosis who presented with a progressively enlarging subcutaneous mass as the primary symptom, and was suspected of having a subcutaneous lipoma after ultrasonography. A review of the literature revealed that soft tissue tuberculosis is insidious and mainly occurs in muscles and subcutaneous tissues. It was indicated by histopathology and qPCR testing for Mycobacterium tuberculosis complex. There is no standard treatment protocol for soft tissue tuberculosis, and a comprehensive regimen of surgical debridement of the lesion combined with chemotherapy can be used following the guidelines for treating extrapulmonary tuberculosis. Early diagnosis and standardized anti-tuberculosis treatment can significantly improve the prognosis of patients.

The value of multimodal ultrasonography in evaluating therapeutic response of cervical tuberculous lymphadenitis to anti-tuberculosis drugs

Purpose

In order to research the value of multimodal ultrasonography in evaluating therapeutic response of cervical tuberculous lymphadenitis to anti-tuberculosis drugs.

Materials and methods

Sixty-one patients with cervical tuberculous lymphadenitis were enrolled in this study. Ultrasound examination was performed before systemic standard anti-tuberculosis treatment and within 1-2 months after treatment, and the patients were divided into effective group and ineffective group according to the follow-up at the sixth month. The multimodal ultrasound signs of the two groups were compared and analyzed.

Results

In the effective group, there were significant differences in the maximum diameter of lymph nodes, the echo of the surrounding tissue and the enlargement of the contrast area before and after treatment (p < 0.05). At 1-2 months after treatment, there were significant differences in the maximum diameter, pus changes, CDFI, elasticity scores, echo of surrounding tissues, changes in enlarged and non-enhanced areas after contrast enhancement between the effective group and the ineffective group (p < 0.05).

Conclusion

The multimodal ultrasound signs of the appearance of internal pus or non-enhancement area enlargement, enhanced echo of the surrounding tissue and enlargement after CEUS are related to poor prognosis, and may be used to evaluate the response of anti-tuberculosis chemotherapy when the size change of lymph node is not obvious in individual treatment.

Several Potential Serum Proteomic Biomarkers for Diagnosis of Osteoarticular Tuberculosis Based on Mass Spectrometry

BACKGROUND

Osteoarticular tuberculosis is one of the extrapulmonary tuberculosis (EPTB) diseases, which is mainly caused by infection of Mycobacterium tuberculosis (MTB) in bone and joints. The limitation of current clinical test methods is leading to a high misdiagnosis rate and affecting the treatment and prognosis. This study aims to search serum biomarkers that can assist in the diagnosis of osteoarticular tuberculosis.

METHODS

Proteomics can serve as an important method in the discovery of disease biomarkers. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to analyze proteins in 90 serum samples, which were collected from June 2020 to December 2021, then evaluated by statistical analysis to screen potential biomarkers. After that, potential biomarkers were validated by ELISA and diagnostic models were also established for observation of multi-index diagnostic efficacy.

RESULTS

118 differential expressed proteins (DEPs) were obtained in serum after statistical analysis. After the diagnostic efficacy evaluation and clinical verification, inter-alpha-trypsin inhibitor heavy chain H2 (ITIH2), complement factor H-related protein 2 (CFHR2), complement factor H-related protein 3 (CFHR3) and complement factor H-related protein 5 (CFHR5) were found as potential biomarkers, with 0.7167 (95%CI: 0.5846-0.8487), 0.8600 (95%CI: 0.7701-0.9499), 0.8150 (95%CI: 0.6998-0.9302), and 0.9978 (95%CI: 0.9918-1.0040) AUC value, respectively. The remaining DEPs except CFHR5 were constructed as diagnostic models, the diagnostic model contained CFHR2 and CFHR3 had good diagnostic efficacy with 0.942 (95%CI: 0.872-0.980) AUC value compared to other models.

CONCLUSION

This study provides a reference for the discovery of serum protein markers for osteoarticular tuberculosis diagnosis, and the screened DEPs can also provide directions for subsequent pathogenesis research.

Clinicopathological profile of peritoneal tuberculosis and a new scoring model for predicting mortality: an international ID-IRI study

Existing literature about peritoneal tuberculosis (TBP) is relatively insufficient. The majority of reports are from a single center and do not assess predictive factors for mortality. In this international study, we investigated the clinicopathological characteristics of a large series of patients with TBP and determined the key features associated with mortality. TBP patients detected between 2010 and 2022 in 38 medical centers in 13 countries were included in this retrospective cohort. Participating physicians filled out an online questionnaire to report study data. In this study, 208 patients with TBP were included. Mean age of TBP cases was 41.4 ± 17.5 years. One hundred six patients (50.9%) were females. Nineteen patients (9.1%) had HIV infection, 45 (21.6%) had diabetes mellitus, 30 (14.4%) had chronic renal failure, 12 (5.7%) had cirrhosis, 7 (3.3%) had malignancy, and 21 (10.1%) had a history of immunosuppressive medication use. A total of 34 (16.3%) patients died and death was attributable to TBP in all cases. A pioneer mortality predicting model was established and HIV positivity, cirrhosis, abdominal pain, weakness, nausea and vomiting, ascites, isolation of Mycobacterium tuberculosis in peritoneal biopsy samples, TB relapse, advanced age, high serum creatinine and ALT levels, and decreased duration of isoniazid use were significantly related with mortality (p < 0.05). This is the first international study on TBP and is the largest case series to date. We suggest that using the mortality predicting model will allow early identification of high-risk patients likely to die of TBP.

Diagnostic Performance of Different Laboratory Methods for the Detection of Extrapulmonary Tuberculosis

Accurate and appropriate extrapulmonary tuberculosis (EPTB) diagnosis remains challenging due to its paucibacillary nature, requirement of invasive collection procedures, and lack of sensitive tests. This study investigated the diagnostic performance of different methods for the diagnosis of EPTB. A total of 1340 EPTB specimens were collected from presumptive EPTB patients from four different hospitals between November 2015 and March 2017. The collected specimens were tested with AFB microscopy, culture, Xpert MTB/RIF assay (Xpert), and MTBDRplus assay. Among the 1340 EPTB specimens, 49 (3.66%), 141 (10.52%), 166 (12.39%), and 154 (11.49%) were positive in AFB microscopy, culture, Xpert MTB/RIF, and MTBDRplus assay, respectively. A total of 194 (14.9%) cases were found positive in at least one of these methods. Using culture as a reference standard, the sensitivity and specificity of AFB microscopy, Xpert MTB/RIF, and MTBDRplus assay were: 27.0%/99.1%, 83.7%/96.0%, and 79.4%/96.5%, respectively. Compared to the composite reference standard, the sensitivity of culture, AFB microscopy, Xpert MTB/RIF, and MTBDRplus assay was 72.7%, 25.3%, 85.6%, and 79.4%, respectively, with a specificity of 100% for all the methods. The Xpert MTB/RIF assay showed the highest sensitivity compared to other methods. Considering the short turnaround time and promising findings, Xpert MTB/RIF assay should be integrated into national TB guidelines as a routine diagnostic test.

Adrenal Tuberculosis: A Case Report and Literature Review

Adrenal tuberculosis (TB) is a rare disease, which is difficult to diagnose because of its atypical symptoms. We reported a 41-year-old female who was admitted to hospital due to a left adrenal tumor, which was found in health examination without any symptoms. Abdominal CT showed a mass in her left adrenal. The results of blood test were normal. A retroperitoneal laparoscopic adrenalectomy was carried out, and adrenal TB was finally pathologically diagnosed. Following this, examinations focusing on TB were conducted which revealed negative results except for T-cell enzyme-linked immunospot. After the operation, the hormone level was normal. However, a wound infection occurred, which was recovered after antituberculosis treatment. In conclusion, even if there is no evidence of TB, we should be alert when diagnosing adrenal masses. Examinations of pathology, radiography, and hormone play important roles in determining the definite diagnosis of adrenal TB.

A simple heat-based alternative method for deparaffinization of histological sections significantly improves acid-fast staining results for Mycobacteria in tissue

Histopathology is the study of how disease alters human and animal tissue and is based on the microscopic examination of stained tissue sections. To maintain tissue integrity, preserving it from degradation, it is initially fixed, primarily with formalin, before being treated with alcohol and organic solvents, allowing the infiltration of paraffin wax. The tissue can then be embedded in a mold and sectioned, usually at a thickness between 3 and 5 μm, before staining with dyes or antibodies to demonstrate specific components. As the paraffin wax is insoluble in water, it is necessary to remove it from the tissue section before applying any aqueous or water-based dye solution, to allow the tissue to successfully interact with the stain. This deparaffinization/hydration step is normally carried out using xylene, an organic solvent, followed by hydration using graded alcohols. However, this use of xylene has been shown to have detrimental effects on acid-fast stains (AFS), such as those employed to demonstrate Mycobacterium, including the causative agent of tuberculosis (TB), as the integrity of the lipid-rich wall present in these bacteria may be compromised using xylene. A simple, novel method, Projected Hot Air Deparaffinization (PHAD) removes the solid paraffin from the tissue section without the use of any solvents, which produces significantly improved staining results using AFS. PHAD relies on the projection of hot air onto the histological section to melt and remove paraffin from the tissue, which can be achieved using a common hairdryer. •PHAD relies on the projection of hot air onto the histological section which can be achieved using a common hairdryer.•The blowing force is such that melted paraffin is removed from the tissue in 20 min.•Subsequent hydration allows for using aqueous histological stains with success, such as the fluorescent auramine O acid-fast-stain.

Epidemiology of extrapulmonary tuberculosis in central Guangxi from 2016 to 2021

The burden of extrapulmonary tuberculosis (EPTB) has gradually increased in recent years, but not enough epidemiological data is available from central Guangxi. To better understand the epidemiology of EPTB in central Guangxi and identify risk factors associated with them, we retrospectively investigated the epidemiology of tuberculosis (TB), especially EPTB, among patients admitted to the Chest Hospital of Guangxi Zhuang Autonomous Region between 2016 and 2021. We excluded those infected with both pulmonary tuberculosis (PTB) and EPTB, reported the proportion and incidence of PTB or EPTB, and compared the demographic characteristics and risk factors of EPTB and PTB cases using univariate and multivariate logistic regression models. Among 30,893 TB patients, 67.25% (20,774) had PTB and 32.75% (10,119) had EPTB. Among EPTB, pleural, skeletal, lymphatic, pericardial, meningeal, genitourinary, intestinal, and peritoneal TB accounted for 49.44%, 27.20%, 8.55%, 4.39%, 3.36%, 1.48%, 0.87%, and 0.79%, respectively. Patients who were younger (age < 25), from rural areas, Zhuang and other ethnic groups, and diagnosed with anemia and HIV infection were more likely to develop EPTB. However, patients with diabetes and COPD were less likely to have EPTB. From 2016 to 2021, the proportion of PTB cases decreased from 69.73 to 64.07%. The percentage of EPTB cases increased from 30.27 to 35.93%, with the largest increase in skeletal TB from 21.48 to 34.13%. The epidemiology and risk factors of EPTB in central Guangxi are different from those of PTB. The incidence of EPTB is increasing and further studies are needed to determine the reasons for it.

Identification of host biomarkers from dried blood spots for monitoring treatment response in extrapulmonary tuberculosis

There is a lack of objective tools for monitoring treatment response in extrapulmonary tuberculosis (EPTB). This study aimed to explore the utility of inflammatory biomarkers from the dry blood spots (DBS) as a tool for monitoring treatment response in EPTB. In a prospective cohort study, 40 inflammatory biomarkers were investigated in DBS samples from 105 EPTB cases using a Luminex platform. The samples were taken before, and, at the end of the 2nd and 6th months of treatment. A total of 11 inflammatory host biomarkers changed significantly with treatment in all EPTB patients. CXCL9/MIG, CCL20, CCL23, CXCL10/IP-10, CXCL1, CXCL2, and CXCL8 significantly declined in our cohort of EPTB (48 TB pleuritis and 57 TB lymphadenitis) patients at both time points. A biosignature consisting of MIG, CCL23, and CXCL2, corresponded with the treatment response in 81% of patients in the 2nd month and 79% of patients at the end of treatment. MIG, CCL23, IP-10, and CXCL2 changed significantly with treatment in all patients including those showing partial clinical response at the 2nd month of treatment. The changes in the levels of inflammatory biomarkers in the DBS correspond with the treatment success and can be developed as a routine test in low-resource settings.

Efficacy of LAMP assay for Mycobacterial spp. detection to prevent treatment delays and onset of drug resistance: a systematic review and meta-analysis

Background

Tuberculosis (TB) remains a deadly disease affecting one-third population globally. Long turnaround time and poor sensitivity of the conventional diagnostics are the major impediments for faster diagnosis of Mycobacterial spp to prevent drug resistance. To overcome these issues, molecular diagnostics have been developed. They offer enhanced sensitivity but require sophisticated infrastructure, skilled manpower and remain expensive.

Methods

In that context, loop-mediated isothermal amplification (LAMP) assay, recommended by the WHO in 2016 for TB diagnosis, sounds as a promising alternative that facilitates visual read outs. Therefore, the aim of the present study is to conduct a meta-analysis to assess the diagnostic efficiency of LAMP for the detection of a panel of Mycobacterium spp. following PRISMA guidelines using scientific databases. From 1600 studies reported on the diagnosis of Mycobacterium spp., a selection of 30 articles were identified as eligible to meet the criteria of LAMP based diagnosis.

Results

It was found that most of the studies were conducted in high disease burden nations such as India, Thailand, and Japan with sputum as the most common specimen to be used for LAMP assay. Furthermore, IS6110 gene and fluorescence-based detections ranked as the most used target and method respectively. The accuracy and precision rates mostly varied between 79.2% to 99.3% and 73.9% to 100%, respectively. Lastly, a quality assessment based on QUADAS-2 of bias and applicability was conducted.

Conclusion

LAMP technology could be considered as a feasible alternative to current diagnostics considering high burden for rapid testing in low resource regions.

Diagnosis of extrapulmonary tuberculosis by ultrasound-guided biopsy: A retrospective comparison study

Objective

To compare the diagnostic performance of laboratory assays on the ultrasound-guided core needle biopsy samples for diagnosis of extra-pulmonary tuberculosis (EPTB) in HIV-positive and HIV-negative patients.

Methods

A total of 217 patients suspected to have EPTB underwent lesion biopsy from 2017 to 2020. Results of laboratory tests on the biopsy and non-biopsy samples were collected with clinical data for retrospective analysis of test utility. The calculated diagnostic accuracy of the tests was stratified according to the specimen types and HIV status.

Results

The cohort contained 118 patients with a final positive diagnosis of extrapulmonary tuberculosis (EPTB group, 54.4%) and 99 finally diagnosed as without TB (non-EPTB group, 45.6%). The risk factor for EPTB was HIV co-infection (OR 2.22, 95% CI 1.17-4.28, p = 0.014). In biopsy samples, GeneXpert (Xpert) showed higher sensitivity (96.6% [91.6-98.7], p < 0.0001) than culture (56.1% [47.0-64.9]). Regardless of HIV status, Xpert had the highest sensitivity (>95%) and specificity (nearly 100%) of any methods. In non-biopsy samples, only T-SPOT.TB (T-SPOT) showed higher sensitivity than culture (90.9% [62.3-99.5] vs 35.3% [17.3-58.7], p = 0.0037). Furthermore, the sensitivities of Xpert were lower in non-biopsy samples (60.0% [23.1-92.9], p = 0.022) than in biopsy samples (100% [86.7-100]). Even in smear-negative biopsy samples, Xpert still had higher sensitivity than culture and retained high specificity (100% [95.7-100]).

Conclusion

Superior performance of Xpert in diagnosing EPTB was observed regardless of HIV status and specimen types. Nevertheless, the biopsy samples still substantially facilitated the accurate diagnosis of extrapulmonary tuberculosis.

Epidemiological and Cytokine Profile of Patients with Pulmonary and Extrapulmonary Tuberculosis in a Population of the Brazilian Amazon

Several factors are associated with the development of different clinical forms of tuberculosis (TB). The present study evaluated epidemiological variables and cytokine levels in samples from 89 patients with TB (75 with pulmonary TB and 14 with extrapulmonary TB) and 45 controls. Cytokines were measured by flow cytometry (Human Th1/Th2/Th17 Cytometric Bead Array kit). The TB group had a higher frequency of individuals who were 39 years of age or older, married, with primary education or illiterate and had a lower family income (p < 0.05). All individuals with extrapulmonary TB reported that they were not working, and the main reasons were related to disease symptoms or treatment. The levels of IFN-γ (OR = 4.06) and IL-4 (OR = 2.62) were more likely to be elevated in the TB group (p = 0.05), and IFN-γ levels were lower in patients with extrapulmonary TB compared to those with pulmonary TB (OR = 0.11; p = 0.0050). The ROC curve was applied to investigate the diagnostic accuracy of IFN-γ levels between the different clinical forms of tuberculosis, resulting in high AUC (0.8661; p < 0.0001), sensitivity (93.85%) and specificity median (65.90%), suggesting that IFN-γ levels are useful to differentiate pulmonary TB from extrapulmonary TB. The dysregulation of pro- and anti-inflammatory cytokine levels represent a risk for the development of TB and contribute to the pathogenesis of the disease, especially variation in IFN-γ levels, which may determine protection or risk for extrapulmonary TB.

Epidemiological characteristics of extrapulmonary tuberculosis patients with or without pulmonary tuberculosis

Our study aimed to investigate the epidemiology of extrapulmonary tuberculosis (EPTB) and analyse the epidemiological characteristics of EPTB patients with or without pulmonary tuberculosis (PTB). EPTB cases admitted in our hospital from January 2015 to December 2020 were included. Uni- and multi-variable logistic regression analysis was carried out to identify risk factors and prognostic factors of concomitant EPTB and PTB or exclusively EPTB. A total of 3488 EPTB patients were reviewed, including 2086 patients with concurrent PTB and EPTB, and 1402 patients with exclusively EPTB. Logistic regression analysis showed that age >60 years (OR = 1.674, 95% CI = 1.438–1.949, P < 0.001) and female (OR = 1.325, 95% CI = 1.155–1.520, P < 0.001) were risk factors of exclusively EPTB, while co-morbidities (OR = 0.676, 95% CI = 0.492–0.929, P = 0.016) and severe symptoms (OR = 0.613, 95% CI = 0.405–0.929, P = 0.021) were risk factors for concurrence of EPTB and PTB. Age >60 years was an independent prognostic factor in EPTB patients with or without PTB (HR = 11.059, 95%CI = 5.097–23.999, P < 0.001; HR = 23.994, 95%CI = 3.093–186.151, P = 0.0020). Female gender was an independent prognostic factor in patients with concurrent PTB and EPTB (HR = 23.994, 95%CI = 3.093–186.151, P = 0.002). Our study disclosed the differential epidemiological characteristics of EPTB patients with or without PTB in China.

Value of Contrast-Enhanced Ultrasound in the Ultrasound Classification of Cervical Tuberculous Lymphadenitis

Purpose

The purpose of this study was to investigate the clinical value of contrast-enhanced ultrasound (CEUS) in the ultrasound (US) classification of cervical tuberculous lymphadenitis (CTL).

Materials and Methods

This retrospective study included 70 patients diagnosed with CTL. All patients underwent both conventional US and CEUS. Both methods were compared to determine their agreement with pathological CTL results.

Results

The results of conventional US classification were as follows: 18 patients (25.7%) were type I, 25 patients (35.7%) type II, 21 patients (30.0%) type III, and 6 patients (8.6%) type IV, respectively. The results of CEUS classification were as follows: 9 patients (12.9%) were type I, 33 patients (47.1%) type II, 22 patients (31.4%) type III, and 6 patients (8.6%) type IV. Conventional US classification and pathological results showed moderate agreement in terms of US classification results for CTL (Kappa = 0.693); the accuracy of conventional US classification was 78.6% (55/70), and the accuracy of types II and III were 71.0% (22/31) and 82.6% (19/23), respectively. CEUS classification and pathological results showed strong agreement (Kappa = 0.871); the accuracy of CEUS classification was 91.4% (64/70), and the accuracy of types II and III were 93.6% (29/31) and 87.0% (20/23), respectively.

Conclusion

In combined with conventional US, CEUS could provide more information on blood flow enhancement patterns and identify the area of lymph node necrosis in CTL. This could contribute to a more accurate US classification of CTL.

Brucellar Knee Arthritis with Knee Joint Tuberculosis: A Case Report and Review of the Literature

Brucella and Mycobacterium tuberculosis (MTB) primarily affect the spine and only rarely the knee joint in osteoarticular disease in adults. We present an unusual instance of brucellar knee arthritis combined with knee joint tuberculosis. A 59-year-old man was initially diagnosed with brucellar knee arthritis in the orthopedics department of our hospital, while two weeks of standardized treatment did not improve the joint discomfort and inflammation indexes. Subsequent evaluation of serum tuberculosis interferon-gamma release assays (TB-IGRAs) and the effectiveness of empirical anti-tuberculosis therapy confirmed the mixed infection of tuberculosis. This case report demonstrates that clinical signs and imaging for brucellar knee arthritis and knee joint tuberculosis are similar. Patients with both disorders are more likely to be misdiagnosed or have their diagnosis delayed; clinicians should be aware of this uncommon combination of mixed infections.

Novel Potential Diagnostic Serum Biomarkers of Metabolomics in Osteoarticular Tuberculosis Patients: A Preliminary Study

Osteoarticular tuberculosis is one of the extrapulmonary tuberculosis, which is mainly caused by direct infection of Mycobacterium tuberculosis or secondary infection of tuberculosis in other parts. Due to the low specificity of the current detection method, it is leading to a high misdiagnosis rate and subsequently affecting the follow-up treatment and prognosis. Metabolomics is mainly used to study the changes of the body’s metabolites in different states, so it can serve as an important means in the discovery of disease-related metabolic biomarkers and the corresponding mechanism research. Liquid chromatography tandem mass spectrometry (LC-MS/MS) was used to detect and analyze metabolites in the serum with osteoarticular tuberculosis patients, disease controls, and healthy controls to find novel metabolic biomarkers that could be used in the diagnosis of osteoarticular tuberculosis. Our results showed that 68 differential metabolites (p<0.05, fold change>1.0) were obtained in osteoarticular tuberculosis serum after statistical analysis. Then, through the evaluation of diagnostic efficacy, PC[o-16:1(9Z)/18:0], PC[20:4(8Z,11Z,14Z,17Z)/18:0], PC[18:0/22:5(4Z,7Z,10Z,13Z,16Z)], SM(d18:1/20:0), and SM[d18:1/18:1(11Z)] were found as potential biomarkers with high diagnostic efficacy. Using bioinformatics analysis, we further found that these metabolites share many lipid metabolic signaling pathways, such as choline metabolism, sphingolipid signaling, retrograde endocannabinoid signaling, and sphingolipid and glycerophospholipid metabolism; these results suggest that lipid metabolism plays an important role in the pathological process of tuberculosis. This study can provide certain reference value for the study of metabolic biomarkers of osteoarticular tuberculosis and the mechanism of lipid metabolism in osteoarticular tuberculosis and even other tuberculosis diseases.

Exploratory study on the predictive value of ultrasound radiomics for cervical tuberculous lymphadenitis

PURPOSE

To investigate the predictive values of gray-scale ultrasound (G-US) and strain elastic ultrasound (SE-US) radiomic features for cervical tuberculous lymphadenitis (CTL).

MATERIAL AND METHODS

The G-US and SE-US images of 147 patients with pathologically confirmed CTL and 69 non-CTL patients were retrospectively analyzed. A total of 851 imaging features were extracted. The patients were divided into the training set and test set in 7:3 ratio. In the training set, the minimum redundancy maximum relevance (mRMR) and the least absolute shrinkage and selection operator (LASSO) were used for feature selection and modeling. The diagnostic power of G-US and SE-US ultrasound radiomics in identifying CTL was evaluated in test set.

RESULTS

The G-US and SE-US have finally selected 10 and 14 features, respectively. In the G-US group, the diagnostic sensitivity, specificity and accuracy of the training set were 69.7%, 85.7% and 70.0%, respectively, and those values in the test set were 81.3%, 70.0% and 86.4%, respectively. The SE-US group had a sensitivity of 71.7%, a specificity of 81.6%, and an accuracy of 67.0% in the training set, and those parameters in the test set were 81.0%, 75.0%, and 83.7%, respectively. In the G-US group, the positive and negative predictive value of the training set were 0.519 and 0.901, respectively, and those values in the test set were 0.700 and 0.864, respectively. The SE-US group had a positive predictive value of 0.541, and a negative predictive value of 0.885 in the training set, and those parameters in the test set were 0.682 and 0.878, respectively. By Delong test, G-US and SE-US groups showed no significant differences in diagnostic performance between the training and test sets.

CONCLUSIONS

The ultrasound radiomic features of G-US and SE-US exhibited certain predictive potential in detecting CTL, providing a new non-invasive method for clinicians to more accurately evaluate patients with CTL.

Rare presentation of tuberculous hypertrophic pachymeningitis diagnosed by a biopsy of abdominal lymphadenopathy

A 59-year-old man with medical history of diabetes mellitus and hypertension presented with a persistent fever of unknown origin and developed a headache. Laboratory tests, including polymerase chain reaction assays for Mycobacterium tuberculosis, showed no specific abnormal findings in blood or cerebrospinal fluid. Contrast-enhanced computed tomography revealed abdominal paraaortic lymphadenopathy. Abdominal lymph node biopsy showed caseous necrosis and suggested tuberculous lymphadenopathy. Intensive examinations revealed positive T-SPOT.TB test and multiple dural nodular hypertrophic lesions in brain magnetic resonance imaging. After antitubercular treatment, all clinical manifestations and dural nodular lesions improved. Finally, we diagnosed the patient with tuberculous hypertrophic pachymeningitis. To our knowledge, this is the first report of tuberculous hypertrophic pachymeningitis concomitant with abdominal tuberculous lymphadenopathy and no other dissemination. Systematic investigation of tuberculosis is important for pachymeningitis.

Combination of Xpert® MTB/RIF and DetermineTM TB-LAM Ag improves the diagnosis of extrapulmonary tuberculosis at Jimma University Medical Center, Oromia, Ethiopia

BACKGROUND

Ethiopia is one of the high burden countries for extrapulmonary tuberculosis (EPTB); however, the prompt diagnosis of EPTB remains challenging. This study is aimed to evaluate the diagnostic performance of Xpert MTB/RIF and DetermineTM TB-LAM Ag (TB-LAM) for the prompt diagnosis of EPTB in Ethiopia.

METHODS

A total of 147 presumptive EPTB patients, including 23 HIV- positive participants were enrolled. Extra-pulmonary samples were collected from all presumptive EPTB cases and tested for Mycobacterium tuberculosis complex (MTBC) using fluorescent microscopy, Xpert MTB/RIF, and culture. Additionally, urine samples were also collected from 126 participants and were tested by DetermineTM TB-LAM Ag (Alere Inc, Waltham, USA). The Sensitivity and specificity of Xpert and TB- LAM tests were calculated by comparing with a composite reference standard (CRS), which comprises smear microscopy, culture and response to empirical anti-TB treatment.

RESULTS

Of 147 patients, 23 (15.6%) were confirmed EPTB cases (culture-positive), 14 (9.5%) were probable EPTB (clinically, radiologically or cytologically positive and received anti-TB treatment with good response), and 110 (74.8%) were classified as "non- TB" cases. Compared to the composite reference standard (CRS), the overall sensitivity and specificity of Xpert MTB/RIF were 43.2% and 100%, respectively with the highest sensitivity for Lymph node aspirate (85.7%) and lower sensitivity for pleural fluid (14.3%) and 100% specificity for all specimen types. The sensitivity and specificity of TB-LAM were 33.3% and 94.4% respectively with the highest sensitivity for HIV co-infected participants (83.3%). The sensitivity of the combination of Xpert MTB/RIF and TB-LAM tests regardless of HIV status was 61.1% whereas the sensitivity was improved to 83.3% for HIV-positive cases.

CONCLUSION

TB-LAM alone has low sensitivity for EPTB diagnosis; however, the combination of TB-LAM and Xpert MTB/RIF improves the diagnosis of EPTB particularly for countries with high EPTB and HIV cases.

Tuberculosis-Specific Antigen/Phytohemagglutinin Ratio Combined With GeneXpert MTB/RIF for Early Diagnosis of Spinal Tuberculosis: A Prospective Cohort Study

Spinal tuberculosis (TB), the most common form of musculoskeletal tuberculosis, is an infection-related disease globally, with paraplegia occurring in severe cases. Therefore, identification of spinal TB at an early stage is important for early intervention and eventual therapy. In this study, we conducted a prospective cohort study in routine clinical practice to investigate the diagnosis of different TB tests. A total of 519 patients were recruited based on the radiology of spinal TB. The diagnostic model was computed by regression analysis and was determined by receiver operating characteristic (ROC) curve analysis. Specificity, sensitivity, predictive value, likelihood ratio, and accuracy were also computed and compared. GeneXpert MTB/RIF showed a higher positive rate compared to that in the acid-fast bacilli smear and Mycobacterium culture. The results also showed that the Mycobacterium tuberculosis-specific antigen/phytohemagglutinin ratio in the T-SPOT assay had a good performance in the preoperative diagnosis and prediction of spinal TB. The diagnostic model based on the ratio of tuberculosis-specific antigen/phytohemagglutinin combined with GeneXpert MTB/RIF showed better efficiency for spinal TB diagnosis. In summary, the tuberculosis-specific antigen/phytohemagglutinin ratio combined with GeneXpert MTB/RIF could provide an early diagnosis of spinal TB.

Improved diagnosis of extrapulmonary tuberculosis in adults with and without HIV in Mbeya, Tanzania using the MPT64 antigen detection test

Extrapulmonary tuberculosis (EPTB) in People Living with HIV (PLWHIV) is a diagnostic challenge. Our immunochemistry based MPT64 antigen detection test has shown improved sensitivity compared to current laboratory tests in the resource limited diagnostic setting. The aim of this study was to validate the implementability and diagnostic performance of the test in PLWHIV and HIV negative adults in a HIV endemic Tanzanian setting. Adult (>18 y) presumptive EPTB patients were prospectively enrolled at Mbeya Zonal Referral Hospital and followed to the end of treatment or until an alternative diagnosis was reached. Suspected sites of infection were sampled and were subject to routine diagnostics, GeneXpert MTB/RIF assay and the MPT64 test. The performance of the diagnostics tests was assessed using a composite reference standard that included clinical suspicion, mycobacterial culture, response to anti-tuberculosis (TB) therapy, cytological and radiological findings. Patients (N = 168) were categorized as 21 confirmed TB, 23 probable TB and 44 possible TB cases, 69 patients were categorized as non-TB cases and 11 were uncategorized. In the TB group, the three most common infections were adenitis (41%), peritonitis (19%) and pleuritis (14%). The TB and non-TB groups did not differ in HIV seropositivity (46% vs 42%) Among HIV negative and PLWHIV, the MPT64 test had a sensitivity of (91% vs 78%), specificity (75% vs 86%), positive predictive value (80% vs 88%), negative predictive value (89% vs 74%), and accuracy (84% vs 81%), respectively. Performance was not significantly reduced in PLWHIV, and sensitivity was higher than in the currently used tests, including the GeneXpert MTB/RIF assay. The MPT64 test improved the diagnosis of EPTB, irrespective of HIV status. The test performed better than currently used diagnostic test. The test was implementable in a tertiary level hospital with basic pathology services in a HIV endemic Tanzanian setting.

Clinical characteristic, Common sites and Drug resistance profile in Culture-confirmed EPTB/ HIV co-infection patients, Southwest of China

OBJECTIVES

There are few reports on EPTB/HIV co-infection patients, especially the drug resistance profile of culture-confirmed EPTB. The purpose of our study was to analysis the clinical characteristic, common sites and drug resistance profile of culture-confirmed EPTB/HIV co-infection patients in recent years in southwest of China.

METHODS

A total of 201 EPTB/HIV co-infection cases were selected for this study. Patient demographic and clinical characteristics were collected. Mycobacterium tuberculosis drug sensitivity testing was performed using the microporousplate ratio method.

RESULTS

For the 2884 culture-confirmed EPTB cases recruited, patients were predominantly male1921/2884(66.6%). Mean age was 31years. Two hundred and one cases were EPTB/ HIV co-infection patients(7.0 %), from 201 cases male make up 84.6% (170/201), mean age was 42 years (range 13-86/year). During the 7-years period, the mean number of EPTB/ HIV co-infection cases was 29 per year(range 12-49/year) at this institution. Diarrhea, headache and fever were the most common presenting symptom.DST results showed the resistance to any anti-tuberculosis drug was observed in 62(30.8%) patient isolates, while multidrug-resistant TB and extensively drug-resistant TB were found in 14(7.0%) and 10(5.0%) patients, respectively. The distribution of EPTB tissue type mainly in Meningeal and Lymph node, varies between different genders.

CONCLUSIONS

The immune level of EPTB/HIV co-infected patients was low and most were in advanced AIDS stage. Mainly young male, and the site of EPTB was mainly in the Meningeal and Lymph node. The most common symptoms were diarrhea, headache and fever and high rates of drug resistance were found.

Insight into diagnosis of female genital tuberculosis

INTRODUCTION

Female genital tuberculosis (TB) is a common manifestation of extrapulmonary TB (EPTB) with varied clinical presentations, i.e. infertility, pelvic pain and menstrual irregularities. Diagnosis of female genital TB is challenging predominantly due to paucibacillary nature of specimens and inconclusive results obtained by most of the routine laboratory tests.

AREAS COVERED

This review has briefly summarized the epidemiology, clinical features and transmission of female genital TB. Commonly used laboratory tests include bacteriological examination (smear/culture), tuberculin skin testing, interferon-γ release assays, imaging, laparoscopy/hysteroscopy and histopathological/cytological observations. Further, utility of nucleic acid amplification tests (NAATs), like loop-mediated isothermal amplification, PCR, multiplex-PCR, nested PCR, real-time PCR and GeneXpert® could significantly improve the detection of female genital TB.

EXPERT OPINION

Currently, there is no single test available for the efficient diagnosis of female genital TB, rather a combination of tests is being employed, which yields moderate diagnostic accuracy. The latest modalities developed for diagnosing pulmonary TB and other clinical EPTB forms, i.e. aptamer-linked immobilized sorbent assay, immuno-PCR (I-PCR), analysis of circulating cell-free DNA by NAATs, and identification of Mycobacterium tuberculosis biomarkers within extracellular vesicles of bodily fluids by I-PCR/nanoparticle-based I-PCR, may also be exploited to further improve the diagnosis of female genital TB.

Delayed diagnosis of active pulmonary tuberculosis - potential risk factors for patient and healthcare delays in Portugal

BACKGROUND

Early diagnosis and treatment of pulmonary tuberculosis (PTB) is essential for an effective control of the tuberculosis (TB) epidemic. Delayed diagnosis and treatment of TB increases the chance of complications and mortality for the patients, and enhances TB transmission in the population. Therefore, the aim of this study was to characterize patient, healthcare and total delay in diagnosing PTB and assess the effect of clinical and sociodemographic factors on the time until first contact with healthcare or reaching a PTB diagnosis.

METHODS

Retrospective cohort study that included active PTB patients notified in the National Tuberculosis Surveillance System (SVIG-TB), between 2008 and 2017. Descriptive statistics, Kaplan-Meier estimates, logrank test and Cox proportional hazards model were used to characterize patient, healthcare and total delay and estimate the effect of clinical and sociodemographic variables on these delays. Significance level was set at 0.05.

RESULTS

Median patient, healthcare and total delays was 37 days (Interquartile range (IQR): 19-71), 8 days (IQR: 1-32) and 62 days (IQR: 38-102), respectively. The median patient delay showed a constant increase, from 33 days in 2008 to 44 days in 2017. The median total delay presented a similar trend, increasing from 59 days in 2008 to 70 days in 2017. Healthcare delay remained constant during the study period. More than half of the PTB cases (82.9%) had a delay > 1 month between symptom onset and diagnosis. In the final Cox model, alcohol abuse, unemployment and being from a high TB incidence country were factors significantly associated with longer patient delay, while being female, having more than 45 years, oncologic and respiratory diseases were associated with longer healthcare delay. Being female, having more than 45 years and being from a high TB incidence country were associated with longer total delay.

CONCLUSIONS

Patient delay and total delay have increased in recent years. Older patients, patients with alcohol problems, other comorbidities, unemployed or from countries with high TB incidence would benefit from the development of specific public health strategies that could help reduce the delay in TB diagnosis observed in our study. This study emphasizes the need to promote awareness of TB in the general population and among the healthcare community, especially at ambulatory care level, in order to reduce the gap between beginning of symptoms and TB diagnosis.

Disseminated tuberculosis mimicking abdominal metastatic carcinoma: A case report

RATIONALE

Extra-pulmonary tuberculosis (TB) has long been a diagnostic challenge for clinicians, often requiring extensive workup and invasive procedures, with the risk of significant complications. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a minimally invasive and highly accurate diagnostic modality for the evaluation of mediastinal and abdominal lymphadenopathy and masses. Several reports on the utility of EUS-FNA as a favorable method for diagnosing extrapulmonary TB have been published.

PATIENT CONCERNS

A 54-year-old man complained of intermittent melena.

DIAGNOSES

18 fluorine-fluorodeoxyglucose positron emission tomography/computed tomography revealed suspected carcinoma metastasis. EUS-FNA did not reveal any evidence of malignancy.

INTERVENTIONS AND OUTCOMES

Laparoscopy was performed, and frozen section pathology during surgery showed granulomas with focal necrosis. Mycobacterium tuberculosis polymerase chain reaction was positive, but acid-fast bacilli staining was negative. Anti-TB treatment was initiated, and the patient was advised to visit the local TB dispensary regularly.

LESSONS

The presence of atypical inflammation of inadequate material or non-representative samples of extra-pulmonary TB was observed on EUS-FNA cytology. Mycobacterium tuberculosis polymerase chain reaction and acid fast bacilli should be performed to diagnose TB because of its higher sensitivity.

Simultaneous determination of three antituberculosis drugs in the serum of patients with spinal tuberculosis by capillary electrophoresis

The pharmacokinetic variations of a single drug in an antituberculosis regimen are associated with acquired drug resistance and therapy failure. This study aimed to develop a simple and effective method for monitoring the serum levels of isoniazid (INH), rifampicin (RFP), and pyrazinamide (PZA), three antibiotics used in patients with spinal tuberculosis using capillary electrophoresis (CE). A standard solution of INH, RFP, and PZA was prepared and mixed with serum to prepare the standard curve. The detection limit, quantification limit, precision, stability, repeatability, and sample recovery were determined. Then, INH, RFP, and PZA were measured from the leftover serum samples of all patients with spinal tuberculosis who were treated with 2SHRZ/2.5H2R2Z2 combined with surgery in a tertiary hospital in Qinghai from October 2015 to September 2017. A total of 107 patients with spinal tuberculosis treated using the 2SHRZ/2.5H2R2Z2 regimen combined with surgery were included in this study. All three antibiotics had linear standard curves with high correlation coefficients (R² = 0.9997, 0.9994, and 0.9986). The recovery rates were 98.1% for INH, 96.5% for PZA, and 97.2% for RFP. The results from the serum samples showed that the plasma concentrations of INH (4.989 ± 1.692 μg mL^-1) and RFP (9.400 ± 1.711 μg mL^-1) reached effective therapeutic concentrations in all patients, but not PZA (33.860 ± 1.830 μg mL^-1). The CE method for measuring INH, RFP, and PZA simultaneously in serum samples of patients with spinal tuberculosis is simple, rapid, and sensitive. This method is suitable for the routine monitoring of INH, RFP, and PZA concentrations in the serum of patients with spinal tuberculosis.

Evaluation of effectiveness of pathology reports in active surveillance of tuberculosis

OBJECTIVE

Despite advancing technology, national TB surveillance systems are still inadequate in terms of patient detection around the world. It was aimed to investigate suspicious cases detected by active surveillance method in pathology laboratories and to evaluate the effectiveness of this method in terms of finding new TB cases.

METHODS

This is a descriptive cross-sectional study. It was administrated in Samsun, Turkey, between January 2012-December 2017. Within the scope of active surveillance, pathology laboratories were regularly visited and reported cases with granulomatous inflammation were assessed. The obtained patient list was compared with the records of the Electronic Tuberculosis Management System (ETMS). Patients who were not included in these records were invited to the dispensary and evaluated for TB. They were also referred to the relevant hospitals for diagnosis if necessary. Frequency values and descriptive statistics were calculated using SPSS method.

RESULTS

It was found that 35.6% of 703 patients with the diagnosis of granulomatous inflammation were previously diagnosed, treated or currently undergoing treatment in the ETMS registry. As a result of the assessment of remaining 453 cases, 46 patients (10.1%) were newly diagnosed with TB. Newly diagnosed TB patients were reported, and their treatment started.

CONCLUSION

As a result, active surveillance method conducted in pathology laboratories are used to detect unknown or late reported TB cases and allows to start treatment without further delay.

Developing Recombinant Antibodies by Phage Display Against Infectious Diseases and Toxins for Diagnostics and Therapy

Antibodies are essential molecules for diagnosis and treatment of diseases caused by pathogens and their toxins. Antibodies were integrated in our medical repertoire against infectious diseases more than hundred years ago by using animal sera to treat tetanus and diphtheria. In these days, most developed therapeutic antibodies target cancer or autoimmune diseases. The COVID-19 pandemic was a reminder about the importance of antibodies for therapy against infectious diseases. While monoclonal antibodies could be generated by hybridoma technology since the 70ies of the former century, nowadays antibody phage display, among other display technologies, is robustly established to discover new human monoclonal antibodies. Phage display is an in vitro technology which confers the potential for generating antibodies from universal libraries against any conceivable molecule of sufficient size and omits the limitations of the immune systems. If convalescent patients or immunized/infected animals are available, it is possible to construct immune phage display libraries to select in vivo affinity-matured antibodies. A further advantage is the availability of the DNA sequence encoding the phage displayed antibody fragment, which is packaged in the phage particles. Therefore, the selected antibody fragments can be rapidly further engineered in any needed antibody format according to the requirements of the final application. In this review, we present an overview of phage display derived recombinant antibodies against bacterial, viral and eukaryotic pathogens, as well as microbial toxins, intended for diagnostic and therapeutic applications.

Peritoneal Tuberculosis Mimicking Ovarian Cancer: Gynecologic Ultrasound Evaluation with Histopathological Confirmation

Peritoneal tuberculosis (TBP) is a very rare condition, accounting for about 1–2% of all tuberculosis cases. The diagnosis of TBP can be easily mistaken for advanced ovarian cancer (AOC) or peritoneal carcinoma because of overlapping laboratory and clinical findings. We reported the ultrasound characteristics of a case of TBP in a 67-year-old woman who presented to our institute with a 1-month history of intermittent lower abdominal pain, fever, and asthenia. Overall, 20 biopsy-retrieved specimen histopathological features were suggestive of peritoneal tuberculosis. Gynecologic ultrasound revealed increased adnexa with multiple nodular formations spread across the surface, suggestive of caseous nodules. Although this is a rare occurrence, clinicians should consider TBP as a differential diagnosis of ovarian or peritoneal cancer.

Differential Expression of Activation Markers by Mycobacterium tuberculosis-specific CD4+ T Cell Distinguishes Extrapulmonary From Pulmonary Tuberculosis and Latent Infection

BACKGROUND

Diagnosis of active tuberculosis (ATB) currently relies on detection of Mycobacterium tuberculosis (Mtb). Identifying patients with extrapulmonary TB (EPTB) remains challenging because microbiological confirmation is often not possible. Highly accurate blood-based tests could improve diagnosis of both EPTB and pulmonary TB (PTB) and timely initiation of anti-TB therapy.

METHODS

A case-control study was performed using discriminant analyses to validate an approach using Mtb-specific CD4+T-cell activation markers in blood to discriminate PTB and EPTB from latent TB infection (LTBI) as well as EPTB from PTB in 270 Brazilian individuals. We further tested the effect of human immunodeficiency virus (HIV) coinfection on diagnostic performance. Frequencies of interferon-γ +CD4+T cells expressing CD38, HLADR, and/or Ki67 were assessed by flow cytometry.

RESULTS

EPTB and PTB were associated with higher frequencies of CD4+T cells expressing CD38, HLADR, or Ki67 compared with LTBI (all P values < .001). Moreover, frequencies of HLADR+ (P = .03) or Ki67+ (P < .001) cells accurately distinguished EPTB from PTB. HIV infection did not affect the capacity of these markers to distinguish ATB from LTBI or EPTB from PTB.

CONCLUSIONS

Cell activation markers in Mtb-specific CD4+T cells distinguished ATB from LTBI and EPTB from PTB, regardless of HIV infection status. These parameters provide an attractive approach for developing blood-based diagnostic tests for both active and latent TB.

Retrospective Study of Bone-TB in Oman: 2002-2019

Objective: Little information is available about the etiology, pathophysiology, risk factors, and epidemiologic features of Bone Tuberculosis (Bone-TB). In this work, we present the epidemiological data about the Bone-TB in the Sultanate of Oman.

Methods: Retrospectively, we identified and assessed those patients who were diagnosed with Bone-TB between January 2002 and December 2019 at Khoula Hospital. The following data were collected: demographics, clinical presentation, anatomical location, diagnosis, and treatment of the Bone-TB.

Results: During the study period, 115 cases of Bone-TB were diagnosed. Males were affected more than females (57.4% and 42.6%, respectively). About 30% of Bone-TB cases were primary diagnosed in other organs particularly the lungs and then after disseminated to the bone. However, the Bone-TB was detected in hip, leg, hand, shoulder, and skull bones, the most detected Bone-TB was in spine (66% of cases). After vaccination the Bacillus Calmette–Guérin (BCG) strains were identified in the bones of eight babies. Tubercle bacilli were detected by Acid-Fast Stain (AFS) in 59% of cases, and the rest of cases were confirmed using polymerase chain reaction (PCR) tests. There are two used treatment regimens, with 12.4% relapse. The gastrointestinal tract (GIT) disturbances were the most related side effects. The resistance has been detected to pyrazinamide in six cases, rifampicin in three cases, and isoniazid, streptomycin and kanamycin were detected in one case.

Conclusion: The most predominant Bone-TB cases were spine-TB that were mainly disseminated from the lungs. AFS failed to detect tubercle bacilli in 40% of cases. There is no statistical significance in relapse between the used two regimens. The death was predominant among skull-TB cases.

Examination of respiratory specimens improves microbiological diagnosis of patients with presumptive extrapulmonary tuberculosis

OBJECTIVES

Bacteriological confirmation of extrapulmonary tuberculosis (EPTB) is challenging for several reasons: the paucibacillary nature of the sample; scarce resources, mainly in middle and low-income countries; the need for hospitalization; and unfavorable outcomes. We evaluated the diagnostic role of respiratory specimen examination prospectively in a cohort of patients with presumptive EPTB.

METHODS

From July 2018 to January 2019, in a tuberculosis (TB)/HIV reference hospital, a cohort of 157 patients with presumed EPTB was evaluated. Xpert® MTB/RIF Ultra or a culture-positive result was considered for bacteriologically confirmed TB.

RESULTS

Out of 157 patients with presumptive EPTB, 97 (62%) provided extrapulmonary and respiratory specimens and 60 (38%) extrapulmonary specimens only. Of the 60 patients with extrapulmonary samples, 5 (8%) were positive. Of those with respiratory and extrapulmonary samples, 27 (28%) were positive: 10 in both the respiratory and extrapulmonary samples, 6 in the extrapulmonary sample only, and 11 in the respiratory sample only. A respiratory specimen examination increased by 6-fold the chance of bacteriological confirmation of TB (odds ratio = 5.97 [1.11-47.17]).

CONCLUSION

We conclude that respiratory samples should be examined in patients with presumptive EPTB.

Role of ultrasound in the diagnosis of cervical tuberculous lymphadenitis in children

BACKGROUND

To describe sonographic characteristics of cervical tuberculous lymphadenitis (CTBL) in children, clinical information, and sonograms of 348 lymph nodes (LNs) from 57 children with CTBL were retrospectively analyzed in this study.

METHODS

We retrospectively reviewed the clinical data and sonograms of 348 LNs from 31 boys and 26 girls with CTBL, who were confirmed by pathology or laboratory examination, at the Hangzhou Red Cross Hospital between June 2014 and December 2020. The age of the children ranged from 1 to 14 years (average 7.1 ± 2.9 years).

RESULTS

Night sweats, fatigue and loss of appetite were the most common clinical symptoms observed in children with CTBL. Unilateral LN involvements were common. Occasionally, CTBL was found in healthy children with no symptoms. On sonography, the hilus was absent or unclear in all LNs. The short-to-long axis (S/L) ratio was ≥ 0.5, and the edges were unclear in most LNs. Other accompanying findings included necrosis (47.4%), an echogenic thin layer (36.8%), surrounding soft-tissue edema (38.5%), multiple intra-nodal strong echo (28.2%), sinus (22.7%) and abscess formation (6.9%). The Doppler ultrasound showed that the majority of vascularity patterns of CTBL were capsular or peripheral (33.3%).

CONCLUSIONS

Ultrasound is a recommended examination method for children from different age groups with cervical lymphadenitis. The ultrasonic signs of hilus absence, S/L ratio ≥ 0.5, unclear edge, necrosis, echogenic thin layer, strong echoes and capsular or peripheral vascularity may aid in the diagnosis of cervical tuberculous lymphadenitis.

Isolated splenic Mycobacterium tuberculosis complex infection in an immunocompetent individual with FDG-PET positive mass

Tuberculosis, caused by Mycobacterium tuberculosis complex, is a leading cause of mortality in the world, and 15% of the patients may present with extrapulmonary diseases, including splenic lesion. However, isolated splenic infection with M. tuberculosis complex is very rare. A 19-year-old otherwise healthy woman presented with left flank pain, revealing FDG-avid nodules in the spleen. She did not have pulmonary lesions. Histopathology of splenectomized sample showed granuloma, and subsequent PCR revealed amplification of IS6110, a genetic sequence exclusively detected in M. tuberculosis complex. A wide range of differential diagnosis of isolated splenic lesion should include M. tuberculosis infection regardless of pulmonary involvement. An elective splenectomy may be mandatory in timely manner.

Immunometabolism during Mycobacterium tuberculosis Infection

Over a quarter of the world's population is infected with Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis (TB). Approximately 3.4% of new and 18% of recurrent cases of TB are multidrug-resistant (MDR) or rifampicin-resistant. Recent evidence has shown that certain drug-resistant strains of Mtb modulate host metabolic reprogramming, and therefore immune responses, during infection. However, it remains unclear how widespread these mechanisms are among circulating MDR Mtb strains and what impact drug-resistance-conferring mutations have on immunometabolism during TB. While few studies have directly addressed metabolic reprogramming in the context of drug-resistant Mtb infection, previous literature examining how drug-resistance mutations alter Mtb physiology and differences in the immune response to drug-resistant Mtb provides significant insights into how drug-resistant strains of Mtb differentially impact immunometabolism.

Clinical outcomes of new algorithm for diagnosis and treatment of Tuberculosis sepsis in HIV patients

Background

Despite effort to diagnose tuberculosis (TB) in the Human Immunodeficiency Virus (HIV) infected population, 45% of adults with HIV that had a previously unknown reason for death, demonstrated TB was the cause by autopsy examination. We aimed to assess the clinical outcomes of implementation a new algorithm for diagnosis and treatment of tuberculosis (TB) related sepsis among PLHIV presenting with life-threatening illness.

Methods

This study is a prospective cohort conducted in three-referral hospitals in Kilimanjaro, recruited 97 PLHIV from February through June 2018. Patients provided urine and sputum samples for testing lateral flow - lipoarabinomannan (LF-LAM) and Xpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF) assays, respectively. Anti-TB was prescribed to patients with positive LF-LAM or Xpert MTB/RIF or received broad-spectrum antibiotics but deteriorated.

Results

Of 97 patients, 84 (87%) provided urine and sputa, and 13 (13%) provided only urine. The mean age (95% confidence interval) was 40 (38-43) years and 52 (54%) were female. In 84 patients, LF-LAM increased TB detection from 26 (31%) by Xpert MTB/RIF to 41 (55%) by both tests. Of 97 patients, 69 (71%) prescribed anti-TB, 67% (46/69) and 33% (23/69) had definitive and probable TB respectively. Sixteen (16.5%) patients died, of which one died before treatment, 73% (11/15) died within 7 days of admission. The 30-day survival was similar in both treatment groups (log rank = 0.1574). Mortality was significantly higher among hospitalized patients compared to outpatients (P ≤ 0.027).

Conclusion

Implementation of new algorithm increased TB case detection in patients that could have been missed by Xpert MTB/RIF assay. Survival of PLHIV with confirmed or probable TB was comparable to those of PLHIV that were treated with broad-spectrum antibiotics alone. Further work should focus on the optimal timing and content of the immediate antimicrobial regimen for sepsis among PLHIV in TB-endemic settings.

Screening and identification of serum biomarkers of osteoarticular tuberculosis based on mass spectrometry

BACKGROUND

In view of the current difficulty of clinically diagnosing osteoarticular tuberculosis, our aim was to use mass spectrometry to establish diagnostic models and to screen and identify serum proteins which could serve as potential diagnostic biomarkers for early detection of osteoarticular tuberculosis.

METHODS

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) was used to select an osteoarticular tuberculosis-specific serum peptide profile and establish diagnostic models. Further, liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to identify potential serum biomarkers that could be used for auxiliary diagnosis of osteoarticular tuberculosis, and then clinical serum samples were used to verify these biomarkers by enzyme-linked immunosorbent assay (ELISA).

RESULTS

We established four diagnostic models that can distinguish osteoarticular tuberculosis from rheumatoid arthritis, ankylosing spondylitis, osteoarticular infections, and healthy adults. The models were osteoarticular tuberculosis-rheumatoid arthritis, osteoarticular tuberculosis-ankylosing spondylitis, osteoarticular tuberculosis-osteoarticular infections, and osteoarticular tuberculosis-healthy adult, and their accuracy was 76.78%, 79.02%, 83.77%, and 88.16%, respectively. Next, we selected and identified 18 proteins, including complement factor H-related protein 1 (CFHR1) and complement factor H-related protein 2 (CFHR2), which were upregulated in the tuberculosis group only.

CONCLUSIONS

We successfully established four diagnostic models involving osteoarticular tuberculosis, rheumatoid arthritis, ankylosing spondylitis, osteoarticular infections, and healthy adults. Furthermore, we found that CFHR1 and CFHR2 may be two valuable auxiliary diagnostic indicators for osteoarticular tuberculosis. These results provide reference values for rapid and accurate diagnosis of osteoarticular tuberculosis.

Diagnosing peritoneal tuberculosis

Peritoneal tuberculosis (TB) is one of the most challenging forms of extrapulmonary tuberculosis to diagnose. This challenge can be compounded in low incidence regions, and in patients with cirrhosis in whom the presence of ascites alone may not prompt further investigation. A delay in the diagnosis and treatment of peritoneal tuberculosis may lead to worse clinical outcomes. This case describes a 64-year-old Italian male with decompensated cirrhosis being evaluated for liver transplantation, who developed abdominal pain and a persistent inflammatory ascites with peritoneal thickening despite antibiotic therapy. Peritoneal tuberculosis was suspected, although non-invasive and invasive direct mycobacterial testing remained negative. A constellation of positive QuantiFERON-TB Gold In-Tube test, elevated ascitic adenosine deaminase and dramatic symptomatic and radiographic response to empiric anti-tuberculous therapy confirmed the diagnosis of peritoneal tuberculosis. This paper will review the approach to the diagnosis of peritoneal tuberculosis.

Diagnosis and clinical outcomes of extrapulmonary tuberculosis in antiretroviral therapy programmes in low- and middle-income countries: a multicohort study

INTRODUCTION

Extrapulmonary tuberculosis (EPTB) is difficult to confirm bacteriologically and requires specific diagnostic capacities. Diagnosis can be especially challenging in under-resourced settings. We studied diagnostic modalities and clinical outcomes of EPTB compared to pulmonary tuberculosis (PTB) among HIV-positive adults in antiretroviral therapy (ART) programmes in low- and middle-income countries (LMIC).

METHODS

We collected data from HIV-positive TB patients (≥16 years) in 22 ART programmes participating in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in sub-Saharan Africa, Asia-Pacific, and Caribbean, Central and South America regions between 2012 and 2014. We categorized TB as PTB or EPTB (EPTB included mixed PTB/EPTB). We used multivariable logistic regression to assess associations with clinical outcomes.

RESULTS AND DISCUSSION

We analysed 2695 HIV-positive TB patients. Median age was 36 years (interquartile range (IQR) 30 to 43), 1102 were female (41%), and the median CD4 count at TB treatment start was 114 cells/μL (IQR 40 to 248). Overall, 1930 had PTB (72%), and 765 EPTB (28%). Among EPTB patients, the most frequently involved sites were the lymph nodes (24%), pleura (15%), abdomen (11%) and meninges (6%). The majority of PTB (1123 of 1930, 58%) and EPTB (582 of 765, 76%) patients were diagnosed based on clinical criteria. Bacteriological confirmation (using positive smear microscopy, culture, Xpert MTB/RIF, or other nucleic acid amplification tests result) was obtained in 897 of 1557 PTB (52%) and 183 of 438 EPTB (42%) patients. EPTB was not associated with higher mortality compared to PTB (adjusted odd ratio (aOR) 1.0, 95% CI 0.8 to 1.3), but TB meningitis was (aOR 1.9, 95% CI 1.0 to 3.1). Bacteriological confirmation was associated with reduced mortality among PTB patients (aOR 0.7, 95% CI 0.6 to 0.8) and EPTB patients (aOR 0.3 95% CI 0.1 to 0.8) compared to TB patients with a negative test result.

CONCLUSIONS

Diagnosis of EPTB and PTB at ART programmes in LMIC was mainly based on clinical criteria. Greater availability and usage of TB diagnostic tests would improve the diagnosis and clinical outcomes of both EPTB and PTB.

Clinical characteristics that portend a positive Xpert Ultra test result in patients with pleural tuberculosis

BACKGROUND

The performance of Xpert-MTB/RIF, including the newer Xpert Ultra test, for the diagnosis of pleural TB is poor (~28 - 38%). There are no data on patient characteristics that portend a positive Xpert-Ultra test in pleural fluid. These characteristics could be useful for selecting patients for Xpert-Ultra testing, thus maximising benefits of a positive test, while minimising cost.

OBJECTIVES

To determine the clinical, radiological, microbiological and biochemical characteristics associated with Xpert-Ultra positivity in patients with suspected pleural tuberculosis.

METHODS

We performed a subgroup analysis of a prospective observational cohort (N=165 patients with suspected pleural TB) evaluating same-day diagnostic tools for pleural tuberculosis. Forty-nine patients with confirmed pleural tuberculosis (culture and/or histology) were included in the final analysis.

RESULTS

Of the 49 participants, 17 (35%) were female and 9 (18.4%) were HIV-infected. In the multivariate analysis including demographic, radiological and pleural fluid test characteristics, there were no independent predictors of Xpert-Ultra positivity. However, when pleural fluid test results were excluded, and when only rapidly ascertainable pre-test factors (demographic and radiologic variables) were considered, the multivariable analysis showed that only a chest X-ray (CXR) suggestive of active TB (cavities, consolidation and hilar lymphadenopathy) was associated with Xpert-Ultra positivity (p=0.021). Notably, only 22% (n=11/49) of the participants had a CXR suggestive of active TB and of these, 73% (n=8/11) had a positive Xpert-Ultra result.

CONCLUSION

CXR features suggestive of active TB are significantly associated with a positive Xpert-Ultra test result on pleural fluid. These data inform clinical practice in resource-poor settings.

A rare case of multi-focal human TB after BCG instillation for non-muscle-invasive bladder cancer

OBJECTIVE

To describe a left epididymitis and para-aortical involvement caused by Mycobacterium tuberculosis hominis reactivation after bacillus Calmette-Guérin instillation for non-muscle-invasive bladder cancer.

PATIENT AND METHODS

A Caucasian male, aged 76 years, exposed to bacillus Calmette-Guérin for a high-grade non-muscle-invasive bladder cancer in 2015, reported painful and progressive left scrotal swelling with purulent discharge from a cutaneous fistulous track that yielded, on liquid culture, a pan-susceptible Mycobacterium tuberculosis hominis strain. Moreover, after 6 months of anti-tuberculosis treatment, an abdominal peri-aortic mass, sized 4 cm, was found and a surgical biopsy showed necrotizing granulomas; however, although smear microscopy and Xpert MTB/Rif™ performed on fresh biopsy sample were positive, liquid cultures resulted negative, indicating treatment efficacy.

RESULTS

Numerous peculiar and multi-organ involvement due to BCGitis after intravesical immunotherapy have been previously described, including 17 scientific articles about epididymitis, however, no reports so far showed reactivation of Mycobacterium tuberculosis hominis after bacillus Calmette-Guérin treatment.

CONCLUSION

Although BCGitis is more prevalent in patients undergoing bacillus Calmette-Guérin instillation for non-muscle-invasive bladder cancer, tuberculosis by other species of Mycobacterium tuberculosis should be always ruled out by molecular and conventional microbiology in patients with a history of Mycobacterium tuberculosis hominis exposure.

An improved algorithm for rapid diagnosis of pleural tuberculosis from pleural effusion by combined testing with GeneXpert MTB/RIF and an anti-LAM antibody-based assay

Background

This retrospective study evaluated the performance of a lipoarabinomannan (LAM)-based immunological method for diagnosing pleural tuberculosis (TB) from pleural effusion samples. Results were compared to those obtained using conventional culture and molecular testing methods.

Methods

Suspected pleural TB patients who visited Beijing Chest Hospital for medical care between January 2016 and June 2017 were retrospectively analysed in the study. Pleural effusion samples were tested for Mycobacterium tuberculosis (MTB) using the BACTEC MGIT 960 System, GeneXpert, and an anti-LAM antibody assay (LAM assay).

Results

Pleural effusion samples were collected from a total of 219 retrospectively recruited participants suspected of having pleural TB. Thirteen of 155 confirmed pleural TB cases tested positive for MTB via MGIT culture, for a sensitivity of 8.4% [95% confidence interval (CI): 4.0–12.8%]. In addition, GeneXpert and LAM testing identified 22 and 55 pleural TB cases, for sensitivities of 14.2% (95% CI: 8.7–19.7%) and 35.5% (95% CI: 28.1–43.6%), respectively. The specificities of these two assays were 100.0% (95% CI: 92.9–100.0%) and 96.9% (95% CI: 88.2–99.5%), respectively. Combined application of culture and LAM testing identified 60 positive cases, for a sensitivity of 38.7% (95% CI: 31.0–46.4%) that was significantly higher than that of MGIT culture alone (P < 0.01). Similarly, use of LAM testing in combination with GeneXpert led to correct diagnosis of 40.0% (95% CI: 32.3–47.7%) of pleural TB cases, a higher rate than obtained using GeneXpert alone (P < 0.01). In addition, the specificity of the combined assay of GeneXpert and LAM testing was 96.9% (95% CI: 88.2–99.5%). Patients aged 25 to 44 years were more likely to have positive LAM assay results than those ≥65 years of age (P = 0.02). Meanwhile, the proportion of diabetic patients with positive LAM assay results was significantly lower than that of the non-diabetes group (P = 0.03).

Conclusions

An anti-LAM antibody detection assay showed potential for diagnosis of pleural TB from pleural effusion samples. Combined use of the LAM assay with MGIT culture or GeneXpert methods could improve sensitivity for improved pleural TB diagnosis compared to results of individual conventional tests alone.

Percutaneous ultrasound-guided laser ablation for the treatment of cervical tuberculous lymphadenitis: a pilot study

OBJECTIVE

This study was performed to assess the feasibility, effectiveness, and safety of percutaneous ultrasound (US)-guided laser ablation (LA) for the treatment of cervical tuberculous lymphadenitis (CTBL).

METHODS

We retrospectively reviewed 11 patients with CTBL (mean age, 32.0 ± 8.6 years; range, 18-47 years) who underwent percutaneous US-guided LA from June 2014 to December 2016 with a subsequent 12-month follow-up. We assessed the mean volume reduction and contrast-enhanced US (CEUS) changes of the target lymph nodes as well as the tolerability and adverse effects of LA.

RESULTS

The mean ablation energy was 522 ± 312 J (range, 204-1317 J). All 17 enrolled target lymph nodes were completely non-enhanced after LA treatment as detected by CEUS, indicating complete ablation of all lymph nodes (100%). The target lymph nodes significantly decreased in volume by a mean of 74.0% ± 15.6% from baseline to 12 months after LA. The LA procedure was well tolerated, and none of the 11 patients developed severe complications during the 12-month follow-up.

CONCLUSION

Percutaneous US-guided LA for the treatment of CTBL exhibits good tolerability, minimal invasiveness, and few adverse effects. Further investigations with larger sample sizes and longer follow-up periods are warranted to confirm these findings.

Detection of the tuberculosis biomarker mannose-capped lipoarabinomannan in human serum: Impact of sample pretreatment with perchloric acid

The development of an accurate and rapid diagnostic test for tuberculosis (TB) to use at point of need is vital to efforts aimed at reducing the global burden from this disease. This paper builds on our previous studies of mannose-capped lipoarabinomannan (ManLAM) as a serum biomarker for active TB infection by means of a heterogeneous immunoassay. That work found that complexation with components in serum (e.g., proteins) sterically hindered the capture and/or labeling of ManLAM in an immunoassay at levels <10 ng mL-1, compromising the clinical utility of this biomarker for detection of active TB infection. We also showed that the acidification of ManLAM-containing serum samples with perchloric acid improved the detectability of ManLAM by 250× by complex disruption when compared to measurements of untreated serum. The present study examined what effects the PCA treatment of serum samples may have on the recovery and structural integrity of ManLAM, owing to its potential susceptibility to acid hydrolysis. Recovery was assessed with an enzyme-linked immunosorbent assay (ELISA). The possible impact of acid hydrolysis on the ManLAM structure was investigated by gas chromatography-mass spectrometry and carbohydrate chemical degradation methods. The ELISA study indicated that while the signal strength for ManLAM in the serum spike-in experiments was significantly stronger after PCA pretreatment when compared to untreated human serum, it was only ∼20% of the ManLAM measured in physiological buffer. This loss in detectability was shown by structural analysis to arise mainly from the acid-induced degradation of the arabinan domains of ManLAM that are targeted by antibodies used for antigen capture and/or tagging. The implications of these findings in terms of the detection of this important biomarker for TB are also discussed.