Gastric lavage in the diagnosis of pulmonary tuberculosis in children: a systematic review

Diagnostic Accuracy of Cartridge Based Nucleic Acid Amplification Test (CBNAAT) in Stool Samples in Pediatric Tuberculosis

OBJECTIVES

To find out the diagnostic accuracy of stool Cartridge-based nucleic acid amplification test (CBNAAT) as an alternate method as compared to CBNAAT in gastric aspirate (GA) samples in pediatric tuberculosis (TB).

METHODS

This cross-sectional study was performed at Department of Pediatrics of a tertiary care hospital. Children aged 0-18 y diagnosed as presumptive tuberculosis were consecutively enrolled. Gastric aspirate and corresponding stool sample was subjected to CBNAAT and its performance was compared in both samples using appropriate statistical tests.

RESULTS

Total 100 patients were enrolled in the study. Diagnostic accuracy of CBNAAT was 81% and 80% in gastric aspirate and stool sample respectively. On comparing gastric aspirate with corresponding stool sample there was 97% agreement, with Cohen's kappa value of 0.94. There was a statistically significant association observed between gastric aspirate CBNAAT and stool CBNAAT p <0.001 using chi square test. Sensitivity of gastric aspirate CBNAAT and stool CBNAAT was 75% and 73% respectively and specificity was 100% for both the samples compared against Composite Reference Standard (CRS).

CONCLUSIONS

The diagnostic accuracy of stool CBNAAT is comparable to GA CBNAAT in children and can be used as a good alternative to gastric aspirate for diagnosis of pulmonary and disseminated tuberculosis in children.

Effect of time, temperature and pH on Mycobacterium tuberculosis culture positivity of gastric aspirate: An experimental study

BACKGROUND

The culture of gastric aspirate (GA) has been used for bacteriological confirmation of pulmonary tuberculosis in children and patients who are unable to expectorate. Sodium bicarbonate neutralization of gastric aspirates is commonly recommended to increase culture positivity. We aim to study Mycobacterium tuberculosis (MTB) culture positivity of GA collected from confirmed case of pulmonary tuberculosis after storing it at different temperature, pH & time.

METHODS

GA specimens from 865 patients of either sex predominately non-expectorating children/adults with suspected pulmonary TB were collected. Gastric lavage was performed in the morning after an overnight fasting (at least 6hrs fasting). The GA specimens were tested by CBNAAT (GeneXpert) and AFB microscopy & those who were positive on CBNAAT were further processed with MTB culture on Growth Indicator Tube (MGIT™) culture. pH neutralized and non-neutralized CBNAAT positive GA specimens were culture within 2 hours of collection and 24 hours after storage at 4 °C & room temperature.

RESULTS

MTB was detected in 6.8% of collected GA specimens by CBNAAT. Culture positivity of neutralized GA specimens when processed within 2 hours of collection, was higher compared to paired non-neutralized GA specimens. Neutralized GA specimens had higher contamination rate than non-neutralized GA specimens. Storage of GA specimens at $Deg C had better culture yield than those stored at room temperature.

CONCLUSION

Early neutralization of acid in Gastric aspirate (GA) is essential for better culture positivity of M. tuberculosis (MTB). If there is a delay in processing GA, it should be kept at 4 °C after neutralization; however, positivity decreases with time.

A rare case of gastric fundus tuberculosis with nonspecific abdominal pain

A 53-year-old patient who experienced recurring upper abdominal pain and discomfort for 4 years was admitted to our hospital. Gastroscopy was performed to identify the location of the pain and evaluate the characteristics of a mass in the abdomen. Endoscopic ultrasonography (EUS) and abdominal computed tomography (CT) revealed a space-occupying lesion in the gastric fundus, suggestive of a submucosal tumor and highly likely of stromal origin. Surgical resection of the lesion was performed for identification; however, postoperative histopathological examination of the lesion revealed gastric fundus tuberculosis (TB). Gastric TB is relatively rare; therefore, clinicians should be highly suspicious of patients with abdominal symptoms from regions with a high incidence of TB to prevent treatment delay caused by misdiagnosis.

Microbiological Testing of Gastric Aspirate Improves the Diagnosis of Pulmonary Tuberculosis in Unconscious Adults with TB Meningitis

Conventional sputum collection for TB diagnosis is difficult in TB meningitis patients since most of them are admitted with decreased consciousness. It is assumed that unconscious patients swallow their sputum; therefore, gastric aspiration can replace sputum collection in unconscious patients. A prospective study was conducted to see whether examining gastric aspirate could increase the diagnosis certainty of pulmonary TB in such subjects. The inclusion criteria were age 18–60 years, decreased level of consciousness, and use of a nasogastric tube. Subjects who had taken antituberculosis drugs for more than 3 days were excluded. Gastric lavage was performed in the morning after an overnight fast. Specimens were examined for direct smear, culture, and rapid molecular testing. Demographic, clinical, chest X-ray, and laboratory data were also recorded. During the study period, 31 subjects were available. The positivity rates for microbiological tests were 19.3%, 41.9%, and 48.4% for smear, culture, and rapid molecular testing, respectively. All positive smears were confirmed by either culture or rapid molecular testing. Gastric lavage can be considered a tool for improving extraneural TB diagnosis in unconscious patients.

Which sample type is better for Xpert MTB/RIF to diagnose adult and pediatric pulmonary tuberculosis?

Objective: This review aimed to identify proper respiratory-related sample types for adult and pediatric pulmonary tuberculosis (PTB), respectively, by comparing performance of Xpert MTB/RIF when using bronchoalveolar lavage (BAL), induced sputum (IS), expectorated sputum (ES), nasopharyngeal aspirates (NPAs), and gastric aspiration (GA) as sample.

Methods: Articles were searched in Web of Science, PubMed, and Ovid from inception up to 29 June 2020. Pooled sensitivity and specificity were calculated, each with a 95% confidence interval (CI). Quality assessment and heterogeneity evaluation across included studies were performed.

Results: A total of 50 articles were included. The respective sensitivity and specificity were 87% (95% CI: 0.84–0.89), 91% (95% CI: 0.90–0.92) and 95% (95% CI: 0.93–0.97) in the adult BAL group; 90% (95% CI: 0.88–0.91), 98% (95% CI: 0.97–0.98) and 97% (95% CI: 0.95–0.99) in the adult ES group; 86% (95% CI: 0.84–0.89) and 97% (95% CI: 0.96–0.98) in the adult IS group. Xpert MTB/RIF showed the sensitivity and specificity of 14% (95% CI: 0.10–0.19) and 99% (95% CI: 0.97–1.00) in the pediatric ES group; 80% (95% CI: 0.72–0.87) and 94% (95% CI: 0.92–0.95) in the pediatric GA group; 67% (95% CI: 0.62–0.72) and 99% (95% CI: 0.98–0.99) in the pediatric IS group; and 54% (95% CI: 0.43–0.64) and 99% (95% CI: 0.97–0.99) in the pediatric NPA group. The heterogeneity across included studies was deemed acceptable.

Conclusion: Considering diagnostic accuracy, cost and sampling process, ES was a better choice than other sample types for diagnosing adult PTB, especially HIV-associated PTB. GA might be more suitable than other sample types for diagnosing pediatric PTB. The actual choice of sample types should also consider the needs of specific situations.

The Incremental Value of Repeated Induced Sputum and Gastric Aspirate Samples for the Diagnosis of Pulmonary Tuberculosis in Young Children With Acute Community-Acquired Pneumonia

Background.

Mycobacterium tuberculosis (Mtb) contributes to the pathogenesis of childhood acute community-acquired pneumonia in settings with a high tuberculosis burden. The incremental value of a repeated induced sputum (IS) sample, compared with a single IS or gastric aspirate (GA) sample, is not well known.

Methods.

Two IS samples were obtained for Mtb culture from children enrolled as cases in the Pneumonia Etiology Research for Child Health (PERCH) study in South Africa. Nonstudy attending physicians requested GA if pulmonary tuberculosis was clinically suspected. We compared the Mtb yield of 2 IS samples to that of 1 IS sample and GA samples.

Results

. Twenty-seven (3.0%) culture-confirmed pulmonary tuberculosis cases were identified among 906 children investigated with IS and GA samples for Mtb. Results from 2 IS samples were available for 719 children (79.4%). Of 12 culture-confirmed pulmonary tuberculosis cases identified among children with ≥2 IS samples, 4 (33.3%) were negative at the first IS sample. In head-to-head comparisons among children with both GA and IS samples collected, the yield of 1 GA sample (8 of 427; 1.9%) was similar to that of 1 IS sample (5 of 427, 1.2%), and the yield of 2 GA samples (10 of 300; 3.3%) was similar to that of 2 IS samples (5 of 300; 1.7%). IS samples identified 8 (42.1%) of the 19 culture-confirmed pulmonary tuberculosis cases that were identified through submission of IS and GA samples.

Conclusions.

A single IS sample underestimated the presence of Mtb in children hospitalized with severe or very severe pneumonia. Detection of Mtb is enhanced by combining 2 IS with GA sample collections in young children with acute severe pneumonia.

Gastric specimens for diagnosing tuberculosis in adults unable to expectorate in Rawalpindi, Pakistan

Setting: Adult pulmonary tuberculosis (TB) patients unable to expectorate quality sputum represent a diagnostic challenge. A private hospital in Pakistan routinely performs gastric aspiration in adults with difficulties expectorating. Objective: To assess the usefulness of gastric specimens (GS) in diagnosing pulmonary TB (PTB) and drug-resistant TB in adult presumptive TB patients unable to expectorate, and to compare the diagnostic yield and sensitivity of smear, culture and the Xpert^® MTB/RIF assay. Design: This was a comparative cross-sectional study based on retrospective record review. Results: Of 900, 885 and 877 GS tested by smear, Xpert and culture, respectively, interpretable results were obtained for respectively 900 (100%), 859 (97.1%) and 754 (86.0%), with a diagnostic yield of respectively 23.6%, 30.3% and 24.9%. The yield was significantly higher for Xpert in previously treated patients. There were 313 patients with definite TB, defined as positive on Xpert and/or culture. The 82.8% sensitivity of Xpert was significantly higher than that of smear (61.0%) and culture (67.8%). Conclusion: GS obtained by aspiration under routine programme conditions is useful for detecting TB and drug-resistant TB in adult patients unable to expectorate. Xpert, with its rapid testing, high proportion of interpretable results and better sensitivity, can substantially improve the diagnosis of bacteriologically confirmed TB and rifampicin resistance.

Scoring system for the diagnosis of tuberculosis in indigenous children and adolescents under 15 years of age in the state of Mato Grosso do Sul, Brazil

OBJECTIVE

To evaluate the process of diagnosing pulmonary tuberculosis in smear-negative indigenous children and adolescents under 15 years of age with the modified Brazilian National Ministry of Health Scoring System (mBNMH-SS).

METHODS

This was a retrospective descriptive study involving 49 indigenous patients under 15 years of age with tuberculosis, treated between 2007 and 2010 in the state of Mato Grosso do Sul, Brazil.

RESULTS

Of the 49 patients, 27 (56%) were under 5 years of age, 33 (67%) had symptoms suggestive of tuberculosis, 24 (49%) were underweight, and 36 (73.5%) had been BCG vaccinated. The tuberculin skin test was positive in 28 patients (57%), 18 (64%) of whom had an induration > 10 mm. Chest X-rays were performed in 37 (76%) of the patients, 31 (84%) of whom had only one chest X-ray taken. Among those 37 patients, the radiological findings were suggestive of tuberculosis in 16 (43%), infiltration/condensation in 10 (27%), and normal in 4 (11%). The Indigenous Health Care Teams made the diagnosis in 31 (63%) of the cases, using the original BNMH-SS in only 14 (45%). We calculated the mBNMH-SS scores for 30 (61%) of the 49 patients. Among the 30 cases scored, a diagnosis of tuberculosis was found to be highly likely, possible, and unlikely in 16 (53%), 11 (37%), and 3 (10%), respectively.

CONCLUSIONS

The proportion of highly likely and possible diagnoses was consistent with the standard proportion of cases diagnosed by the teams (90%), demonstrating the epidemiological applicability of the mBNMH-SS for the diagnosis of pulmonary tuberculosis in the indigenous population, within the scenario of the health care provided.

[Evidence-based practices published in Brazil: identification and analysis of their types and methodological approches]

This is an integrative review of Brazilian studies on evidence-based practices (EBP) in health, published in ISI/JCR journals in the last 10 years. The aim was to identify the specialty areas that most accomplished these studies, their foci and methodological approaches. Based on inclusion criteria, 144 studies were selected. The results indicate that most EBP studies addressed childhood and adolescence, infectious diseases, psychiatrics/mental health and surgery. The predominant foci were prevention, treatment/rehabilitation, diagnosis and assessment. The most used methods were systematic review with or without meta-analysis, protocol review or synthesis of available evidence studies, and integrative review. A strong multiprofessional expansion of EBP is found in Brazil, contributing to the search for more selective practices by collecting, recognizing and critically analyzing the produced knowledge. The study also contributes to the analysis itself of ways to do research and new research possibilities.

Gastric perforation associated with tuberculosis: a case report

Gastric tuberculosis is a rare presentation of tuberculosis infection. Gastric perforation associated with tuberculosis is exceedingly rare with five previously published cases. We present a case of a male patient that developed presumed gastric tuberculosis secondary to pulmonary tuberculosis infection. He subsequently developed gastric perforation and sepsis, for which he was treated both surgically and medically. Despite ongoing antituberculosis treatment, the patient's condition worsened and the patient died secondary to multiorgan failure. This case highlights gastric perforation as a rare but devastating complication of pulmonary tuberculosis.