Prevalence and determinants of extrapulmonary involvement in patients with pulmonary tuberculosis in a Sub-Saharan African country: a cross-sectional study

Etiology of exudative pleural effusion among adults: differentiating between tuberculous and other causes, a multicenter prospective cohort study

Objectives

Exudative pleural effusions have a broad etiology and usually necessitate further investigative workup, including invasive procedures. This study aimed to evaluate and compare the demographic, clinical, and biochemical characteristics of tuberculous, malignant, and chronic inflammatory pleural effusions.

Methods

This is a 2-year prospective cohort study of patients referred for medical thoracoscopy with an exudative pleural effusion.

Results

A total of 159 patients were enrolled in the study, with a mean age of 42.49 ± 13.8 years and the majority being males 121 (76.1%). As expected, patients with tuberculous effusions were significantly younger than those with non-tuberculous effusions (37.7 ± 10.9 vs 49.1 ± 14.9, P <0.001). Serum analysis showed significantly lower white blood cell count (7.5 × 109/L ± 2.7 vs 9.0 × 109/L ± 3.3, P = 0.004), higher total protein (76.2 g/dL ± 10.1 vs 70.2 g/dL ± 8.9, P <0.001), and higher median C-reactive protein (median 77.5, interquartile range 51-116 vs median 40.5, interquartile range 8-127, P <0.001) among tuberculous compared with non-tuberculosis effusions.

Conclusions

Our study validates previous findings showing similar results in patients with tuberculous pleural effusions. A predictive model incorporating different demographic and clinical/laboratory characteristics may be useful in the early etiologic characterization of exudative pleural effusion.

Factors Associated With Extrapulmonary Tuberculosis in Southeastern Mexico: A Case-Control Study

INTRODUCTION

Extrapulmonary tuberculosis (EPTB) is a disease that can affect any organ or tissue. Due to its potential to cause more dangerous sequelae and the barriers to its timely diagnosis, greater clinical awareness of this disease is crucial. This study aimed to identify the factors associated with EPTB in the population of Oaxaca, Mexico.

METHODS

This is an unpaired case-control study. The cases were patients with EPTB+ while the controls were patients with pulmonary tuberculosis (PTB+) registered in the Tuberculosis Epidemiological Surveillance System. Sociodemographic, clinical, and microbiological variables were recovered. Bivariate analyses were performed and logistic regression analyses were performed to calculate the odds ratio (OR).

RESULTS

A total of 75 EPTB+ cases and 300 PTB+ controls were included. Of the total sample, 57.1% were men and 60.3% indigenous. The most frequent clinical presentations of EPTB+ were nodal (21.3%), miliary (21.3%), and breast (20.0%). According to logistic regression analysis, age <40 years (OR: 2.25 (95% CI: 1.13-4.49), female sex (OR: 1.92 (95% CI: 1.03-3.56)], urban residence (OR: 2.25 (95% CI: 1.11-4.55)), comorbidity with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (OR: 3.46 (95% CI: 1.31-9.10)), dyspnea (OR: 2.67 (1.22-5.82)), and adenopathy (OR: 3.38 (95% CI: 1.42-8.06)) were positively associated with EPTB+.

CONCLUSION

These results can serve as a basis for screening EPTB+, thus improving the preventive and diagnostic capacity of local health services, taking as a starting point women under 40 years of age and patients with HIV/AIDS in urban areas, as well as the presence of adenopathy and dyspnea as clinical characteristics of the disease.

Bacteriologically confirmed extrapulmonary tuberculosis and the associated risk factors among extrapulmonary tuberculosis suspected patients in Ethiopia: A systematic review and meta-analysis

BACKGROUND

The actual burden of bacteriologically confirmed extrapulmonary tuberculosis (EPTB) and risk factors in Ethiopia is not well known due to the lack of a strong surveillance system in Ethiopia. Thus, this study was conducted to estimate the pooled prevalence of bacteriologically confirmed EPTB and the associated risk factors among persons suspected to have non-respiratory tuberculosis in Ethiopia.

METHODS

A systematic review and meta-analysis of published studies reporting the prevalence of EPTB from searched electronic databases; Science Direct, PubMed, and Google Scholar was estimated spread across the research periods, nationally, and in different areas, using a fixed-effects model. We used I2 to analyze heterogeneity in the reported prevalence of bacteriologically confirmed extrapulmonary tuberculosis.

RESULTS

After reviewing 938 research articles, 20 studies (19 cross-sectional and 1 retrospective) from 2003 to 2021 were included in the final analyses. The pooled prevalence of bacteriologically confirmed EPTB was 43% (95%CI; 0.34-0.52, I2 = 98.45%). The asymmetry of the funnel plot revealed the presence of publication bias. Specifically the pooled prevalence of bacteriologically confirmed EPTB based on smear microscopy, Xpert MTB/RIF assay, and culture were 22% (95%CI; 0.13-0.30, I2 = 98.56%), 39% (95%CI; 0.23-0.54, I2 = 98.73%) and 49% (95%CI; 0.41-0.57, I2 = 96.43%) respectively. In this study, a history of pulmonary tuberculosis (PTB) contact with PTB patients, contact with live animals, consumption of raw milk, HIV-positive, male, and lower monthly income, were found to be independently associated with bacteriologically confirmed EPTB.

CONCLUSION

Ethiopia has a high rate of bacteriologically confirmed EPTB. A history of previous PTB, being HIV-positive and having contact with PTB patients were the most reported risk factors for EPTB in the majority of studies. Strengthening laboratory services for EPTB diagnosis should be given priority to diagnose EPTB cases as early as possible.

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.

Anemia as a risk factor for tuberculosis: a systematic review and meta-analysis

BACKGROUND

Tuberculosis is a major public health problem caused by Mycobacterium tuberculosis, occurring predominantly in population with low socioeconomic status. It is the second most common cause of death from infectious diseases. Tuberculosis becomes a double burden among anemic patients. Anemia increases an individual's susceptibility to infectious diseases including tuberculosis by reducing the immunity level. Therefore, the purpose of this study was to determine whether anemia is a risk factor for tuberculosis.

METHOD

Relevant published articles were searched in electronic databases like PubMed, Google Scholar, EMBASE, and Cochrane Library using the following MeSH terms: risk factor, predictors, tuberculosis, TB, Anaemia, Anemia, hemoglobin, Hgb, and Hb. Articles written in the English, observational studies conducted on the incidence/prevalence of tuberculosis among anemic patients, or papers examined anemia as risk factors for tuberculosis were included. From those studies meeting eligibility criteria, the first author's name, publication year, study area, sample size and age of participants, study design, and effect measure of anemia for tuberculosis were extracted. The data were entered using Microsoft Excel and exported to Stata version 11 for analysis. The random-effects model was applied to estimate the pooled OR and HR, and 95% CI. The sources of heterogeneity were tested by Cochrane I-squared statistics. The publication bias was assessed using Egger's test statistics.

RESULTS

A total of 17 articles with a 215,294 study participants were included in the analysis. The odd of tuberculosis among anemic patients was 3.56 (95% CI 2.53-5.01) times higher than non-anemic patients. The cohort studies showed that the HR of tuberculosis was 2.01 (95% CI 1.70-2.37) times higher among anemic patients than non-anemic patients. The hazard of tuberculosis also increased with anemia severity (HR 1.37 (95% CI 0.92-2.05), 2.08 (95% CI 1.14-3.79), and 2.66 (95% CI 1.71-4.13) for mild, moderate, and severe anemia, respectively).

CONCLUSION

According to the current systematic review and meta-analysis, we can conclude that anemia was a risk factor for tuberculosis. Therefore, anemia screening, early diagnose, and treatment should be provoked in the community to reduce the burden of tuberculosis.

The epidemiology of extrapulmonary tuberculosis in China: A large-scale multi-center observational study

Tuberculosis (TB) remains a serious global public health problem in the present. TB also affects other sites (extrapulmonary tuberculosis, EPTB), and accounts for a significant proportion of tuberculosis cases worldwide. In order to comprehensively understand epidemiology of EBTB in China, and improve early diagnosis and treatment, we conducted a large-scale multi-center observational study to assess the demographic data and the prevalence of common EPTB inpatients, and further evaluate the prevalence of EPTB concurrent with Pulmonary tuberculosis (PTB) and the associations between multiple EPTB types and gender-age group in China. All consecutive age≥15yr inpatients with a confirmed diagnosis of EPTB during the period from January 2011 to December 2017 were included in the study. The descriptive statistical analysis included median and quartile measurements for continuous variables, and frequencies and proportions with 95% confidence intervals (CIs) for categorical variables. Multinomial logistic regression analysis was used to compare the association of multiple EPTB types between age group and gender. The results showed that the proportion of 15–24 years and 25–34 years in EPTB inpatients were the most and the ratio of male: female was 1.51. Approximately 70% of EPTB inpatients were concurrent with PTB or other types of EPTB. The most common of EPTB was tuberculous pleurisy (50.15%), followed by bronchial tuberculosis (14.96%), tuberculous lymphadenitis of the neck (7.24%), tuberculous meningitis (7.23%), etc. It was found that many EPTB inpatients concurrent with PTB. The highest prevalence of EPTB concurrent with PTB was pharyngeal/laryngeal tuberculosis (91.31%), followed by bronchial tuberculosis (89.52%), tuberculosis of hilar lymph nodes (79.52%), tuberculosis of mediastinal lymph nodes (79.13%), intestinal tuberculosis (72.04%), tuberculous pleurisy (65.31%) and tuberculous meningitis (62.64%), etc. The results from EPTB concurrent with PTB suggested that females EPTB inpatients were less likely to be at higher risk of concurrent PTB (aOR = 0.819, 95%CI:0.803–0.835) after adjusted by age. As age increasing, the trend risk of concurrent PTB decreased (aOR = 0.994, 95%CI: 0.989–0.999) after adjusted by gender. Our study demonstrated that the common EPTB were tuberculous pleurisy, bronchial tuberculosis, tuberculous lymphadenitis of the neck, tuberculous meningitis, etc. A majority of patients with pharyngeal/laryngeal tuberculosis, bronchial tuberculosis, tuberculosis of hilar/mediastinal lymph nodes, intestinal tuberculosis, tuberculous pleurisy, tuberculous meningitis, etc. were concurrent with PTB. Female EPTB inpatients were less likely to be at higher risk of concurrent PTB, and as age increasing, the trend risk of concurrent PTB decreased. The clinicians should be alert to the presence of concurrent tuberculosis in EPTB, and all suspected cases of EPTB should be assessed for concomitant PTB to determine whether the case is infectious and to help for early diagnosis and treatment.

Optimizing Tuberculosis Diagnosis in Human Immunodeficiency Virus-Infected Inpatients Meeting the Criteria of Seriously Ill in the World Health Organization Algorithm

Background

The World Health Organization (WHO) algorithm for the diagnosis of tuberculosis in seriously ill human immunodeficiency virus (HIV)-infected patients lacks a firm evidence base. We aimed to develop a clinical prediction rule for the diagnosis of tuberculosis and to determine the diagnostic utility of the Xpert MTB/RIF assay in seriously ill HIV-infected patients.

Methods

We conducted a prospective study among HIV-infected inpatients with any cough duration and WHO-defined danger signs. Culture-positive tuberculosis from any site was the reference standard. A priori selected variables were assessed for univariate associations with tuberculosis. The most predictive variables were assessed in a multivariate logistic regression model and used to establish a clinical prediction rule for diagnosing tuberculosis.

Results

We enrolled 484 participants. The median age was 36 years, 65.5% were female, the median CD4 count was 89 cells/µL, and 35.3% were on antiretroviral therapy. Tuberculosis was diagnosed in 52.7% of participants. The c-statistic of our clinical prediction rule (variables: cough ≥14 days, unable to walk unaided, temperature >39°C, chest radiograph assessment, hemoglobin, and white cell count) was 0.811 (95% confidence interval, .802-.819). The classic tuberculosis symptoms (fever, night sweats, weight loss) added no discriminatory value in diagnosing tuberculosis. Xpert MTB/RIF assay sensitivity was 86.3% and specificity was 96.1%.

Conclusions

Our clinical prediction rule had good diagnostic utility for tuberculosis among seriously ill HIV-infected inpatients. Xpert MTB/RIF assay, incorporated into the updated 2016 WHO algorithm, had high sensitivity and specificity in this population. Our findings could facilitate improved diagnosis of tuberculosis among seriously ill HIV-infected inpatients in resource-constrained settings.

Epidemiology and disease burden of tuberculosis in south of Tunisia over a 22-year period: Current trends and future projections

BACKGROUND

Tuberculosis (TB) is a public health problem worldwide. Characterizing its trends over time is a useful tool for decision-makers to assess the efficiency of TB control programs. We aimed to give an update on the current chronological trends of TB in Southern Tunisia from 1995 to 2016 and to estimate future trajectories of TB epidemic by 2030.

METHODS

We retrospectively collected data of all notified TB new cases by the Center of Tuberculosis Control between 1995 and 2016 in South of Tunisia. Joinpoint Regression Analysis was performed to analyze chronological trends and annual percentage changes (APC) were estimated.

RESULTS

In the past 22 years, a total of 2771 cases of TB were notified in Southern Tunisia. The annual incidence rate of TB was 13.91/100,000 population/year. There was a rise in all forms of TB incidence (APC = 1.63) and in extrapulmonary tuberculosis (EPTB) (APC = 2.04). The incidence of TB increased in children and adult females between 1995 and 2016 (APC = 4.48 and 2.37, respectively). The annual number of TB declined in urban districts between 2004 and 2016 (APC = -2.85). Lymph node TB cases increased (APC = 4.58), while annual number of urogenital TB decreased between 1995 and 2016 (APC = -3.38). Projected incidence rates would increase to 18.13 and 11.8/100,000 population in 2030 for global TB and EPTB, respectively.

CONCLUSIONS

Our study highlighted a rise in all forms of TB and among high-risk groups, notably children, females and lymph node TB patients in the last two decades and up to the next one.

Bacteriologically confirmed extra pulmonary tuberculosis and treatment outcome of patients consulted and treated under program conditions in the littoral region of Cameroon

BACKGROUND

Extra-pulmonary tuberculosis (EPTB) is defined as any bacteriologically confirmed or clinically diagnosed case of TB involving organs other than the lungs. It is frequently a diagnostic and therapeutic challenge with paucity of data available. The aim of this study was to assess the prevalence of bacteriologically confirmed EPTB; to determine the most affected organs and to evaluate the therapeutic outcome of EPTB patients treated under program conditions in the littoral region of Cameroon.

METHODS

A descriptive cross-sectional laboratory-based epidemiological survey was conducted from January 2016 to December 2017 and 109 specimens from 15 of the 39 diagnosis and treatment centers in the littoral region were obtained. Two diagnostic methods (Gene Xpert MTB and culture (LJ and MGIT) were used for EPTB diagnosis. Determine HIV1/2 and SD Biolinewere used for HIV diagnosis. Confirmed EPTB cases were treated following the national tuberculosis guide.

RESULTS

The prevalence of bacteriologically confirmed EPTB was 41.3% (45). All 45 cases were sensitive to rifampicin. Males were predominately more infected [26 (57.8%)] likewise the age group 31-45 years with 15 (33.3%) cases. The overall prevalence for HIV was 33.6% (36). HIV infection was present in 28.9% (13) of patients with EPTB. The most affected sites with EPTB were: Lymph nodes (66.5%), pleural cavity (15.6%), abdominal organs (11.1%), neuromeningeal (2.2%), joints (2.2%) and heart (2.2%). Overall, 84.4% of the study participants had a therapeutic success with males responding better 57.9% (p = 0.442). Therapeutic success was better (71.7%) in HIV negative EPTB patients (p = 0.787).

CONCLUSION

The prevalence of bacteriologically confirmed EPTB patients treated under program conditions in the littoral region of Cameroon is high with a therapeutic success of 84.4% and the lymph nodes is the most affected site.

Epidemiology of pericardial diseases in Africa: a systematic scoping review

OBJECTIVES

This scoping review sought to summarise available data on the prevalence, aetiology, diagnosis, treatment and outcome of pericardial disease in Africa.

METHODS

We searched PubMed, Scopus and African Journals Online from 1 January 1967 to 30 July 2017 to identify all studies published on the prevalence, aetiologies, diagnosis, treatment and outcomes of pericardial diseases in adults residing in Africa.

RESULTS

36 studies were included. The prevalence of pericardial diseases varies widely according to the population of interest: about 1.1% among people with cardiac complaints, between 3.3% and 6.8% among two large cohorts of patients with heart failure and up to 46.5% in an HIV-infected population with cardiac symptoms. Tuberculosis is the most frequent cause of pericardial diseases in both HIV-uninfected and HIV-infected populations. Patients with tuberculous pericarditis present mostly with effusive pericarditis (79.5%), effusive constrictive pericarditis (15.1%) and myopericarditis (13%); a large proportion of them (up to 20%) present in cardiac tamponade. The aetiological diagnosis of pericardial diseases is challenging in African resource-limited settings, especially for tuberculous pericarditis for which the diagnosis is not definite in many cases. The outcome of these diseases remains poor, with mortality rates between 18% and 25% despite seemingly appropriate treatment approaches. Mortality is highest among patients with tuberculous pericarditis especially those coinfected with HIV.

CONCLUSION

Pericardial diseases are a significant cause of morbidity and mortality in Africa, especially in HIV-infected individuals. Tuberculosis is the most frequent cause of pericardial diseases, and it is associated with poor outcomes.

Assessment of Extrapulmonary Tuberculosis Using Gene Xpert MTB/RIF Assay and Fluorescent Microscopy and Its Risk Factors at Dessie Referral Hospital, Northeast Ethiopia

BACKGROUND

Tuberculosis is a major public health problem and extrapulmonary tuberculosis (EPTB) accounts for a significant proportion of tuberculosis cases worldwide.

OBJECTIVE

To determine the magnitude of EPTB, associated risk factors, and agreement of diagnostic techniques at Dessie Referral Hospital.

METHODS

A cross-sectional study was conducted on consecutive presumptive EPTB cases from March 1 to June 30, 2017. Sociodemographic characteristics and other variables were collected using a structured questionnaire. Clinical specimens were collected and processed using fluorescent microscopy and Gene Xpert assay. Data was analyzed using SPSS version 20. Chi-square test and logistic regression were done and a P value of ≤0.05 was taken as statistically significant.

RESULTS

From a total of 353 presumptive EPTB cases the overall prevalence of Gene Xpert assay and smear confirmed patients was 8.8% and 2.5%, respectively. Tuberculosis lymphadenitis was the predominant (33.3%) type followed by pleural (11.9%) and peritoneal (6.7%) tuberculosis. Previous history of pulmonary tuberculosis was significantly associated with extrapulmonary infection (AOR:2.8; 95%CI: 1.05-7.54; p=0.04); however, other variables such as age, residence, sex, marital status, occupation, level of education, and monthly income did not show any association.

CONCLUSION

High proportions (71%) of Gene Xpert assay confirmed EPTB patients were smear-negative. Sensitivity of microscopy should be enhanced in resource limited countries like Ethiopia where Gene Xpert machine is not easily accessible.

Estimating the impact of tuberculosis anatomical classification on treatment outcomes: A patient and surveillance perspective analysis

Introduction

Tuberculosis anatomical classification is inconsistent in the literature, which limits current tuberculosis knowledge and control. We aimed to evaluate whether tuberculosis classification impacts on treatment outcomes at patient and aggregate level.

Methods

We analyzed adults from São Paulo State, Brazil with newly diagnosed tuberculosis from 2010–2013. We used an extended clinical classification of tuberculosis, categorizing cases as pulmonary, pulmonary and extrapulmonary, extrapulmonary and miliary/disseminated. Our primary outcome was unsuccessful outcome of treatment. To investigate the reported treatment outcome at the aggregate level, we sampled 500 different “countries” from the dataset and compared the impact of pulmonary and extrapulmonary classifications on the reported treatment success.

Results

Of 62,178 patients, 49,999 (80.4%) were pulmonary, 9,026 (14.5%) extrapulmonary, 1,651 (2.7%) pulmonary-extrapulmonary and 1,502 (2.4%) miliary/disseminated. Pulmonary-extrapulmonary cases had similar unsuccessful outcome of treatment compared with pulmonary (adjusted-OR 1.00, 95%CI, 0.88–1.13, p = 0.941), while extrapulmonary were associated with better (adjusted-OR 0.65, 95%CI, 0.60–0.71, p<0.001) and miliary/disseminated with worse outcomes (adjusted-OR 1.51, 95%CI, 1.33–1.71, p<0.001). We found that 60 (12%) countries would report a difference ≥10% in treatment success depending on whether they reported all clinical forms together (current WHO recommendation) or pulmonary forms alone, overestimating the treatment success of pulmonary forms.

Conclusions

The expanded anatomical classification of tuberculosis was strongly associated with treatment outcomes at the patient level. Remarkably, pulmonary with concomitant extrapulmonary forms had similar treatment outcomes compared with pulmonary forms after adjustment for potential confounders. At the aggregate level, reporting treatment success for all clinical forms together might hide differences in progress between pulmonary and extrapulmonary tuberculosis control.

Comparative Yield of Different Diagnostic Tests for Tuberculosis among People Living with HIV in Western Kenya

BACKGROUND

Diagnosis followed by effective treatment of tuberculosis (TB) reduces transmission and saves lives in persons living with HIV (PLHIV). Sputum smear microscopy is widely used for diagnosis, despite limited sensitivity in PLHIV. Evidence is needed to determine the optimal diagnostic approach for these patients.

METHODS

From May 2011 through June 2012, we recruited PLHIV from 15 HIV treatment centers in western Kenya. We collected up to three sputum specimens for Ziehl-Neelsen (ZN) and fluorescence microscopy (FM), GeneXpert MTB/RIF (Xpert), and culture, regardless of symptoms. We calculated the incremental yield of each test, stratifying results by CD4 cell count and specimen type; data were analyzed to account for complex sampling.

RESULTS

From 778 enrolled patients, we identified 88 (11.3%) laboratory-confirmed TB cases. Of the 74 cases who submitted 2 specimens for microscopy and Xpert testing, ZN microscopy identified 25 (33.6%); Xpert identified those plus an additional 18 (incremental yield = 24.4%). Xpert testing of spot specimens identified 48 (57.0%) of 84 cases; whereas Xpert testing of morning specimens identified 50 (66.0%) of 76 cases. Two Xpert tests detected 22/24 (92.0%) TB cases with CD4 counts <100 cells/μL and 30/45 (67.0%) of cases with CD4 counts ≥100 cells/μl.

CONCLUSIONS

In PLHIV, Xpert substantially increased diagnostic yield compared to smear microscopy and had the highest yield when used to test morning specimens and specimens from PLHIV with CD4 count <100 cells/μL. TB programs unable to replace smear microscopy with Xpert for all symptomatic PLHIV should consider targeted replacement and using morning specimens.

Characteristics of patients co-infected with HIV at the time of inpatient tuberculosis treatment initiation in Yaoundé, Cameroon: a tertiary care hospital-based cross-sectional study

Background

Knowledge of the characteristics of patients co-infected with tuberculosis (TB) and human immunodeficiency virus (HIV) when TB treatment is initiated would allow clinicians to improve care and help policy-makers develop relevant and realistic guidelines. The aim of this study was to describe socio-demographic, clinical, and laboratory characteristics of TB/HIV co-infected patients starting inpatient TB treatment in Yaoundé, Cameroon.

Methods

We conducted a retrospective cross-sectional study, collecting data from medical records of HIV-infected patients with TB, aged 15 years old or more, hospitalized in the Infectious Diseases Unit of the Yaoundé Central Hospital, Cameroon from January 1, 2006 to June 30, 2013.

Results

The mean age of 337 patients meeting study inclusion criteria was 39.3 years. More than half were female (53.4%). Most (89.3%) resided in urban areas, 44.2% had a secondary education, and 46.0% were married. The majority was receiving co-trimoxazole prophylaxis (79.5%), and two thirds were taking antiretroviral therapy (67.4%). The mean duration of known HIV infection before TB treatment was 8.4 months. Most (88.1%) had newly diagnosed TB, rather than relapsed disease. Smear-positive pulmonary TB was documented in a third, (35.3%). Laboratory data revealed a median white blood cell count of 5,100 cells/mm³ (IQR 3,300-7,990 cells/mm³), a median hemoglobin level of 8 g/dl (IQR 7–10 g/dl), and a median CD4 cell count of 102 cells/mm³ (IQR 33–178 cells/mm³). Sex differences in our study included older age in the men (p < 0.001), more of whom were married (p < 0.001) and had achieved a higher level of education (p = 0.042). Men had fewer diagnoses of smear-positive pulmonary TB (p = 0.020). They weighed more than the women (p = 0.001) and had higher hemoglobin levels (p = 0.003).

Conclusions

Suboptimal adherence to WHO treatment recommendations in our Cameroonian study reinforces the importance of prescribing co-trimoxazole in HIV infection and ART for all TB/HIV co-infected persons. We urge that Ministries of Health continue implementing and disseminating guidelines for management of TB/HIV co-infected patients, and we call for measures ensuring that healthcare facilities’ stocks of ART and co-trimoxazole are sufficient to meet the need for both.

Tuberculous Pleural Effusion

When a patient presents with new pleural effusion, the diagnosis of tuberculous (TB) pleuritis should be considered. The patient is at risk for developing pulmonary or extrapulmonary TB if the diagnosis is not made. Between 3% and 25% of patients with TB will have TB pleuritis. The incidence of TB pleuritis is higher in patients who are human immunodeficiency virus (HIV)-positive. Pleural fluid is an exudate that usually has a predominance of lymphocytes. The easiest way to diagnose TB pleuritis in a patient with lymphocytic pleural effusion is to demonstrate a pleural fluid adenosine deaminase level above 40 IU/L. The treatment for TB pleuritis is the same as that for pulmonary TB. Tuberculous empyema is a rare occurrence, and the treatment is difficult.

Clinico-pathological features of tuberculosis due to Mycobacterium tuberculosis Uganda genotype in patients with tuberculous lymphadenitis: a cross sectional study

Background

Tuberculous lymphadenitis is next to pulmonary tuberculosis as the most common cause of tuberculosis. Uganda genotype, one of the sub-lineages of Mycobacterium tuberculosis, is the most prevalent cause of pulmonary tuberculosis in Uganda. We here investigate the clinicopathological characteristics of patients with tuberculous lymphadenitis infected with M. tuberculosis Uganda genotype compared with those infected with M. tuberculosis non-Uganda genotype strains.

Methods

Between 2010 and 2012, we enrolled 121 patients (mean age 28.5 yrs, male 48%; female 52%) with tuberculous lymphadenitis, and categorized them by their M. tuberculosis genotypes. The clinical features and lymph node cytopathological parameters were compared between patients in the Uganda and non-Uganda categories using a crude and multivariable logistic regression model with adjustment for confounding factors.

Results

Of the 121participants, 56 (46%) were infected with strains of Uganda genotype. Patients infected with this genotype had significantly lower frequency of abdominal lymphadenopathy (odds ratio 0.4, p = 0.046) after adjusting for sex, age and HIV. Abdominal lymphadenopathy was also significantly associated with abnormal chest X-ray (p = 0.027).

Conclusion

Tuberculous lymphadenitis patients infected with M. tuberculosis Uganda genotype were significantly less prone to have abdominal lymphadenopathy indicating potential reduced ability to disseminate and supporting the concept that differences in M. tuberculosis genotype may have clinical implications.

Epidemiology of extrapulmonary tuberculosis in Brazil: a hierarchical model

Background

Although extrapulmonary tuberculosis (EPTB) is less frequent than Pulmonary Tuberculosis (PTB) and is a secondary target for national TB control programs, its significance has increased worldwide during the HIV epidemic. The objective of this study was to examine the epidemiology of EPTB in Brazil between 2007 and 2011.

Methods

Cross-sectional study involving all cases of TB reported to the Brazilian Notifiable Diseases Surveillance System (Sistema de Informações de Agravo de Notificação - SINAN) in Brazil between 2007 and 2011. Sociodemographic and clinical characteristics of patients with exclusively PTB and exclusively EPTB were compared. Following analysis with Pearson’s chi-square test, variables with p < 0.05 were included in a hierarchical regression model. Variables with p < 0.05 in the corresponding level were kept in the model.

Results

A total of 427,548 cases of TB were included. Of these, 356,342 cases (83.35%; 95% confidence interval (CI) 83.23% - 83.45%) were PTB, 57,217 (13.37%; 95% CI 13.28% - 13.48%) were EPTB, 13,989 (3.27%; 95% CI 3.21% - 3.32%) were concurrent pulmonary and extrapulmonary TB. Patients with EPTB were mainly white (16.7%), and most (29.1%) patients had five to eight years of education. Among comorbidities, HIV infection was prominent (OR 2.15; 95% CI 2.09 – 2.21), although the proportion of cases awaiting test results or untested was high (39%). Ethanol use (OR 0.45; 95% CI 0.43 – 0.46), diabetes mellitus (OR 0.54; 95% CI 0.51 – 0.57) and mental illness (OR 0.88; 95% CI 0.82 – 0.95) were associated with PTB.

Conclusions

Thirteen percent of patients diagnosed with TB in Brazil have only EPTB. More effective diagnostic strategies and control measures are needed to reduce the number of cases of extrapulmonary TB in Brazil.