Extrapulmonary tuberculosis by nationality, The Netherlands, 1993-2001

Relationship between patient sex and anatomical sites of extrapulmonary tuberculosis in Mali

Background

Contribution of host factors in mediating susceptibility to extrapulmonary tuberculosis is not well understood.

Objective

To examine the influence of patient sex on anatomical localization of extrapulmonary tuberculosis.

Methods

We conducted a retrospective cross-sectional study in Mali, West Africa. Hospital records of 1,304 suspected cases of extrapulmonary tuberculosis, available in TB Registry of a tertiary tuberculosis referral center from 2019 to 2021, were examined.

Results

A total of 1,012 (77.6%) were confirmed to have extrapulmonary tuberculosis with a male to female ratio of 1.59:1. Four clinical forms of EPTB predominated, namely pleural (40.4%), osteoarticular (29.8%), lymph node (12.5%), and abdominal TB (10.3%). We found sex-based differences in anatomical localization of extrapulmonary tuberculosis, with males more likely than females to have pleural TB (OR: 1.51; 95% CI [1.16 to 1.98]). Conversely, being male was associated with 43% and 41% lower odds of having lymph node and abdominal TB, respectively (OR: 0.57 and 0.59).

Conclusion

Anatomical sites of extrapulmonary tuberculosis differ by sex with pleural TB being associated with male sex while lymph node and abdominal TB are predominately associated with female sex. Future studies are warranted to understand the role of sex in mediating anatomical site preference of tuberculosis.

Epidemiology and factors associated with Extra-pulmonary tuberculosis in a Low-prevalence area

Background

Tuberculosis is a global public health problem. Extra-pulmonary tuberculosis accounts for an increasing proportion of cases worldwide, although information about epidemiological, clinical, or microbiological factors is lacking.

Methods

We conducted a retrospective observational study of tuberculosis cases diagnosed between 2016 and 2021, classified into Pulmonary and Extra-pulmonary tuberculosis. Univariable and multivariable logistic regression models were used to investigate risk factors of Extra-pulmonary tuberculosis.

Results

20.9% of overall cases were classified as Extra-pulmonary tuberculosis, with a rising trend from 22.6% in 2016 to 27.9% in 2021. Lymphatic tuberculosis accounted for 50.6% of cases, followed by pleural tuberculosis (24.1%). 55.4% of cases belonged to foreign-born patients. Microbiological culture tested positive in 92.8% of Extra-pulmonary cases. Logistic regression analysis showed that women were more predisposed to develop Extra-pulmonary tuberculosis (aOR 2.46, 95% CI 1.45-4.20) as well as elderly patients (aged ≥ 65 years) (aOR 2.47, 95% CI 1.19-5.13) and persons with previous history of tuberculosis (4.99, 95% CI 1.40-17.82).

Conclusions

Extra-pulmonary Tuberculosis have increased within our study period. A profound decline occurred in 2021 tuberculosis cases, probably due to COVID-19. Women, elderly population, and persons with previous history of tuberculosis are at higher risk of developing Extra-pulmonary tuberculosis in our setting.

Sex and Gender Differences in Tuberculosis Pathogenesis and Treatment Outcomes

Tuberculosis remains a daunting public health concern in many countries of the world. A consistent observation in the global epidemiology of tuberculosis is an excess of cases of active pulmonary tuberculosis among males compared with females. Data from both humans and animals also suggest that males are more susceptible than females to develop active pulmonary disease. Similarly, male sex has been associated with poor treatment outcomes. Despite this growing body of evidence, little is known about the mechanisms driving sex bias in tuberculosis disease. Two dominant hypotheses have been proposed to explain the predominance of active pulmonary tuberculosis among males. The first is based on the contribution of biological factors, such as sex hormones and genetic factors, on host immunity during tuberculosis. The second is focused on non-biological factors such as smoking, professional exposure, and health-seeking behaviors, known to be influenced by gender. In this chapter, we review the literature regarding these two prevailing hypotheses by presenting human but also experimental animal studies. In addition, we presented studies aiming at examining the impact of sex and gender on other clinical forms of tuberculosis such as latent tuberculosis infection and extrapulmonary tuberculosis, which both appear to have their own specificities in relation to sex. We also highlighted potential intersections between sex and gender in the context of tuberculosis and shared future directions that could guide in elucidating mechanisms of sex-based differences in tuberculosis pathogenesis and treatment outcomes.

Role of Gene Xpert in smear negative pulmonary tuberculosis

BACKGROUND

Tuberculosis is a major health problem contributing to significant morbidity and mortality. Early diagnosis and treatment is the key for TB control. Sputum microscopy is a rapid and inexpensive test but due to low and variable sensitivity, many cases can be missed. Culture is considered to be the gold standard but is time consuming. Gene Xpert is a novel and rapid cartridge based nucleic acid amplification test (CBNAAT) that can be used for prompt diagnosis.

AIM

To compare the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of Gene Xpert with culture in diagnosing tuberculosis in sputum smear negative patients.

METHODS

The study is a prospective observational study conducted from December 2017 to January 2019 on 189 patients, who were sputum smear negative but had signs and symptoms suggestive of tuberculosis. Their respiratory samples were taken (either sputum or bronchoalveolar lavage) and sent for Gene Xpert. The results were compared with culture, which was taken as the gold standard, and diagnostic accuracy was assessed.

RESULT

A total of 189 patients were included in the study. In 25 patients sputum was taken and in 164 patients BAL was taken (which included 22 patients in whom sputum Gene Xpert was negative but there was high clinical suspicion of tuberculosis). The sensitivity, specificity, PPV and NPV of Gene Xpert in diagnosing smear negative pulmonary tuberculosis was found to be 96.3%, 81.3%, 87.5% and 94.2% respectively.

CONCLUSION

Gene Xpert can be used as a rapid diagnostic tool in patients who are sputum smear negative but have clinical features highly suggestive of tuberculosis. It additionally helps in detecting rifampicin resistance. But every Gene Xpert positive case does not necessarily mean an active disease, therefore, past history of tuberculosis along with radiological signs of disease activity are to be considered. In case of negative Gene Xpert but high clinico-radiological suspicion of TB, patients should be followed up on regular intervals, while awaiting their culture.

Musculoskeletal tuberculosis revisited: bone and joint tuberculosis in Austria

BACKGROUND

To prevent further spread of the disease and secondary deformity, musculoskeletal tuberculosis (TB) remains a challenge in terms of early diagnosis and treatment. This study gives an overview on TB trends in Austria (pulmonary and extrapulmonary TB) (A) and analyses a retrospective series of musculoskeletal TB cases diagnosed and treated at an Austrian tertiary centre (B).

METHODS

(A) We analysed data obtained from the Austrian national TB registry to provide information on TB patients´ demographics and manifestation sites between 1995 and 2019. (B) Furthermore, we performed an observational study of all patients with a confirmed diagnosis of musculoskeletal TB who were admitted to the Department of Orthopaedics and Trauma, Medical University of Graz (2005-2019). Demographic, diagnostic, clinical and follow-up data were retrieved from the medical records.

RESULTS

(A) From 1995 to 2019, a significant linear reduction in overall Austrian tuberculosis incidence rates occurred (p < 0.001). In the period investigated, Austria recorded a total of 307 patients with musculoskeletal TB. (B) Our retrospective case-series included 17 individuals (9 males, 8 females; average follow-up 48.4 months; range 0-116). There was a biphasic age distribution with a peak in elderly native Austrians (median 69, range 63-92), and a second peak in younger patients with a migration background (median 29, range 18-39). Sites of manifestation were the spine (n = 10), peripheral joints (n = 5), and the soft tissues (n = 2). Diagnosis was based on histology (n = 13), PCR (n = 14), and culture (n = 12). Eleven patients underwent surgery (64.7%). Secondary deformities were frequent (n = 9), and more often observed in patients with spinal TB (n = 6).

CONCLUSION

Musculoskeletal TB should be considered if untypical joint infections or nonspecific bone lesions occur in younger patients with a migration background or in patients with specific risk factors.

Rare manifestation of a large stenosing gastrointestinal tumor caused by Mycobacterium tuberculosis in a previously healthy man from Austria

BACKGROUND

Gastrointestinal tuberculosis (TB) is a rare manifestation in low TB-incidence countries such as Austria. It is usually seen in immunocompromised patients or in migrants being more susceptible for extrapulmonary disease manifestations.

CASE DESCRIPTION

We report a very rare manifestation of severe gastrointestinal TB in a 49-year-old previously healthy man from Upper Austria. Endoscopy showed a large tumor mass obstructing about 2/3 of the lumen of the cecum. Positron emission tomography/computed tomography scan revealed not only a high metabolic activity in the tumor mass, but also active pulmonary lesions in both upper lung lobes. Bronchial secretion showed acid-fast bacilli in the microscopy and polymerase chain reaction was positive for M. tuberculosis complex. Phenotypic resistance testing showed no resistance for first-line anti-TB drugs. Treatment with isoniazid, rifampicin, pyrazinamide and ethambutol was initiated. Based on therapeutic drug monitoring, the standard treatment regime was adapted to rifampicin high dose. TB treatment was well tolerated and the patient achieved relapse-free cure one year after the end of treatment.

CONCLUSION

Gastrointestinal involvement mimicking an intestinal tumor is a very rare TB manifestation in previously healthy Austrians. However, it should be kept in mind due to increasing migration from countries with higher rates of extrapulmonary TB and due to an increasing number of immunocompromised patients. TB telephone consultations can support medical professionals in the diagnosis and the management of complex TB patients. TB management is currently at a transitional stage from a programmatic to personalized management concept including therapeutic drug monitoring or biomarker-guided treatment duration to achieve relapse-free cure.

Multifocal bone tuberculosis simulating metastasis

Multiple skeletal tuberculosis can be the first sign of tuberculosis. In such cases, physicians should consider tuberculosis diagnosis and take biopsies for anatomopathological evidence to make the correct diagnosis.

Rifampin resistance among individuals with extrapulmonary tuberculosis: 4 years of experience from a reference laboratory

Information is limited about the drug resistance patterns in extrapulmonary tuberculosis (EPTB) in Iran. This study aimed to determine the prevalence of EPTB and to investigate the drug-resistance pattern in Mycobacterium tuberculosis strains collected from extrapulmonary samples at the Tehran regional TB reference laboratory. Extrapulmonary specimens from individuals with suspected TB referred to the TB reference laboratories in five cities of Iran were collected. Both standard conventional methods (culture and direct smear microscopy) and Xpert MTB/RIF assay were used for the identification of mycobacteria. Drug susceptibility testing was done using Xpert MTB/RIF. The proportion method on Lowenstein–Jensen medium was performed for confirmation. Between 2016 and 2020, a total of 12 050 clinical specimens from individuals with suspected TB were collected, of which 10 380 (86%) were pulmonary specimens and 1670 (14%) were extrapulmonary. Of the extrapulmonary specimens, 85 (5.0%) were positive for M. tuberculosis, and the remaining 1585 (95.0%) samples were negative by standard methods. Of 85 M. tuberculosis isolates, drug susceptibility testing was performed for 32 isolates, of which 1 (3.1%, 95% CI 0.0%–9.4%) was rifampin resistant and 31 (96.9%, 95% CI 90.1%–100%) were pan-susceptible. The rifampin-resistant isolate was also resistant to isoniazid, so was assigned as a multidrug-resistant TB. Our study indicated the frequency of drug-resistance among EPTB in Iran. Establishing rapid diagnostic methods for detection of drug-resistance in EPTB, performing drug susceptibility testing for all EPTB cases to provide effective treatment, and continuous monitoring of drug resistance, are suggested for prevention and control of drug resistance in EPTB in Iran.

Genital tuberculosis role in female infertility in Portugal

INTRODUCTION

Genitourinary tuberculosis is the fourth most common cause of extrapulmonary tuberculosis, although often underestimated by clinicians due to its rare and non-specific symptoms. One of the disease's complications is infertility. Although Portugal is one of the European countries with the highest prevalence of tuberculosis, its impact on Portuguese female fertility is unknown. With this study, we intend to evaluate the prevalence of genital tuberculosis, its presenting symptoms, and pregnancy outcomes in infertile women followed in a Portuguese tertiary hospital.

METHODS

Retrospective and descriptive study, performed using an electronic database and consultation of clinical files. Studied population: infertile women followed from 2000 until 2019 at the reproductive unit of a Portuguese tertiary hospital, who underwent endometrial biopsy/curettage in the context of their etiological investigation. The diagnosis of genital tuberculosis was based on histological criteria.

RESULTS

Over the 19 years, 2653 endometrial specimens were analyzed. Pathological evaluation was positive for tuberculosis in 19 cases (0.72%). There was a decrease in new diagnoses throughout the observation period.

CONCLUSION

Despite being one of the European countries with the highest prevalence of tuberculosis, genital TB does not appear to have a significant impact on the etiology of female infertility in Portugal. Nevertheless, it is a diagnosis to be considered in selected patients.

Extrapulmonary tuberculosis among migrants in Europe, 1995 to 2017

Objectives

The proportion of tuberculosis (TB) cases occurring in migrants in Europe is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality, yet its extent in migrant populations is unclear. We assessed patterns of extrapulmonary TB in migrants across the European Union (EU)/European Free Trade Association (EFTA). We investigated the proportion of extrapulmonary TB cases among migrants versus non-migrants, and variations by specific site of disease, reporting European region, and migrant region of origin.

Methods

We carried out a cross-sectional secondary database analysis, utilizing 23 years of data collected between 1995 and 2017 from the European Surveillance System of the European Centre for Disease Prevention and Control for 32 EU/EFTA countries.

Results

In total, 1 270 896 TB cases were included, comprising 326 987 migrants (25.7%) and 943 909 non-migrants (74.3%). Of TB cases among migrants, 45.2% (n = 147 814) were extrapulmonary compared to 21.7% (n = 204 613) among non-migrants (p < 0.001). Lymphatic, bone/joint and peritoneal/digestive TB were more common among migrant than non-migrant extrapulmonary cases. A lower proportion of extrapulmonary TB was seen in Eastern Europe (17.4%, n = 98 656 of 566 170) and Southern Europe (29.6%, n = 62 481 of 210 828) compared with Western (35.7%, n = 89 498 of 250 517) and Northern Europe (41.8%, n = 101 792 of 243 381). Migrants from South-East Asia and Sub-Saharan Africa were at highest risk of extrapulmonary disease, with 62.0% (n = 55 401 of 89 353) and 54.5% (n = 38 327 of 70 378) of cases, respectively, being extrapulmonary.

Conclusions

Among TB cases in the EU/EFTA, extrapulmonary disease is significantly more common in migrants than in non-migrants. There is a need to improve clinical awareness of extrapulmonary TB and to integrate its detection into screening programmes.

Epidemiology and the diagnostic challenge of extra-pulmonary tuberculosis in a teaching hospital in Ethiopia

BACKGROUND

Ethiopia reported a high rate of extra-pulmonary tuberculosis (EPTB) and the cases are increasing since the last three decades. However, diagnostic evidence to initiate TB treatment among EPTB cases is not well known. Therefore, we described the epidemiology and assessed how EPTB is diagnosed in a teaching hospital in Ethiopia.

METHODS

We conducted a retrospective review among all adult EPTB cases diagnosed in Yekatit 12 Hospital Medical College from 2015 to 2019. Using a standardized data abstraction sheet, we collected data from patients' medical records on sociodemographic, sites, and laboratory diagnosis of EPTB cases.

RESULTS

Of the 965 total TB cases, 49.8%(481) had a recorded diagnosis of EPTB during the study period. The mean age of EPTB patients was 32.9 years (SD±13.9) and 50.7% were males. Tubercular lymphadenitis (40.3%), abdominal (23.4%), and pleural TB(13.5%) were the most common sites of EPTB involvement, followed in descending order by the genitourinary, skeletal, central nervous system, abscess, breast, and laryngeal TB. We found a histopathology finding consistent with EPTB in 59.1% of cases, Acid-fast bacilli positive in 1.5%, and the rest diagnosed on radiological grounds. In the majority of cases, more than one diagnostic method was used to diagnose EPTB cases.

CONCLUSIONS

Nearly half of TB patients had a recorded diagnosis of EPTB that comprise heterogeneous anatomical sites. All EPTB patients were started anti-TB therapy without definitive microbiology results. This indicates the diagnostic challenge of EPTB faced in our setting and proves to be significant for TB control in Ethiopia.

A rare case of spinal tuberculosis due to Mycobacterium bovis. Is zoonotic tuberculosis underdiagnosed?

We report a rare presentation of Pott's disease caused by M. bovis, suggesting transmission from infected cattle, and only the second case described so far in scientific reports. Noteworthy of this case was that the strain was only isolated on Stonebrink medium, a sodium pyruvate-containing culture medium for the isolation of mycobacteria. This medium is frequently ignored in diagnostic laboratories and in the laboratory manuals of most international health organizations. In general laboratories use a culture medium that contains glycerol, a carbon substrate considered inhibitory for the growth of M. bovis. The use of glycerol-containing medium therefore likely contributes towards underestimating zoonotic tuberculosis. Our case suggests that, in order to improved surveillance efforts for zoonotic TB and increase the notification rate for M. bovis to human TB, the use of pyruvate-containing media should be promoted, particularly in developing countries with a high prevalence of bovine TB, but also through the World Health Organization' (WHO) End TB Strategy and the Roadmap for Zoonotic TB.

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.

Epidemiological Trends in the Form of Childhood Tuberculosis in a Referral Tuberculosis Hospital in Shandong, China

Background

In China, the prevalence of tuberculosis (TB) diseases and epidemiological trends in the TB forms among children are still unclear; a retrospective study was conducted aiming to assess it.

Methods

Between January 2007 and September 2020, 1577 consecutive childhood TB patients (aged ≤ 15 years) were included in the study. Data, including demographic information and underlying diseases, were collected from medical records. Then, patients were categorized and reported according to the anatomical site of TB disease. To analyze the epidemiological trends in the proportion of each form of TB disease, a linear-by-linear association was used, and a P value of <0.05 was considered to indicate that a significant change had occurred in the proportion of TB disease over the studied period.

Results

During the fourteen-year study period, a total of 1577 children patients were enrolled, including 954 boys (60.5%) and 623 girls (39.5%), with a mean age of 9.26 ± 5.18 years. Among the studied patients, 810 (51.4%) patients have pulmonary TB, 1137 (72.1%) have extrapulmonary TB, 372 (23.6%) have both conditions, and another 765 (48.5%) extrapulmonary cases presented in isolated form. Pleural TB (29.0%) and tuberculous lymphadenitis (23.7%) were the most frequent two forms of childhood TB. In addition, during the past decade, the proportions of pulmonary TB, pleural TB, and tuberculous lymphadenitis showed an increasing trend (all P < 0.05). However, no significant trends in the proportions of other forms of TB disease, such as extrapulmonary TB (P > 0.05), tuberculous meningitis (P > 0.05), endobronchial TB (P > 0.05), and disseminated TB (P > 0.05), were found.

Conclusion

Our findings suggest that childhood TB is facing new challenges, and the policy should be adjusted timely to fit the real situation.

Incidence, risk factors and clinical characteristics of extra-pulmonary tuberculosis patients: a ten-year study in the North of Iran

OBJECTIVE

To determine the incidence of extra-pulmonary tuberculosis (EPTB) and examine the risk factors and the clinical features of the disease over a ten-year period.

METHODS

Retrospective study of records of patients who were followed and registered in the TB registry programme in the health district of Gorgan, Iran from January 1, 2008, through December 31, 2017.

RESULTS

Among 2280 TB records, 609 (26.71%) were EPTB. They were mostly female patients (53.7%) and residents in rural areas (56.5%) with a mean age of 40.55 years [±16]. The average age of female patients (37.55 years [±16.99]) was lower than of male patients (44.07 years [±20.59]). The median of the incidence rate was 7.5 per 100 000 inhabitants for EPTB; biopsy and pathology were the best methods for the detection of EPTB. The most frequent forms of EPTB were lymphatic TB (193/609 = 31.7%) and pleural TB (158/609 = 25.9%). In most cases (245/609 = 40.2%), one to three months elapsed between occurrence of symptoms and final confirmation of EPTB. The outcome of EPTB was weaker than of pulmonary TB (PTB).

CONCLUSION

Our most important finding was the increasing incidence of EPTB, which shows the importance of attention to this disease. Lymph node and pleural tissue were the most commonly infected tissues. Skeletal TB presents a challenge in the diagnosis and treatment of EPTB.

Occurrence of multidrug-resistant tuberculous meningitis associated with injury during spinal surgery: A case report

Here we describe a case of multidrug-resistant tuberculous meningitis associated with injury inflicted during spinal surgery. A 54-year-old man was diagnosed with multidrug-resistant spinal tuberculosis (TB). Anterior debridement and fusion with posterior fusion and instrumentation were conducted to remove damaged bone and TB-associated granulomatous tissue. After surgical decompression, a lancet wound (about 5mm in length) was discovered in the cerebral dura mater at the L3 position of the vertebral body. At four weeks post-surgery, the patient experienced fever, hemiparesis, and aphasia. Cerebrospinal fluid (CSF) findings were consistent with TB meningitis, while in vitro susceptibility test results confirmed that the patient had multidrug-resistant TB. Our data highlight a possible TBM infection associated with a surgical lesion in a spinal TB patient. Rapid molecular diagnostics are urgently needed to formulate efficacious regimens for treating these patients.

A retrospective study on Xpert MTB/RIF for detection of tuberculosis in a teaching hospital in China

BACKGROUND

The Xpert MTB/RIF assay is an automated molecular test that is designed to simultaneously detect Mycobacterium tuberculosis (MTB) complex and rifampin resistance. However, there are relatively few studies on this method in China. Xpert has been routinely used at Peking University People's Hospital (PKUPH) since November 2016. Thus, the aim of this study was to evaluate the performance of Xpert, and provide a reference and guidance for the detection and diagnosis of TB in non-TB specialized hospitals.

METHODS

The medical records of inpatients simultaneously tested with Xpert, acid-fast bacilli (AFB) smear microscopy, and interferon-gamma release assay (IGRA, by T-SPOT®.TB) at PKUPH from November 2016 to October 2018 were reviewed. Active TB cases were considered according to a composite reference standard (CRS). Then, the three methods were evaluated and compared.

RESULTS

In total, 787 patients simultaneously tested with Xpert, AFB, and IGRA were enrolled; among them 11.3% (89/787) were diagnosed and confirmed active pulmonary TB (PTB, 52 cases), extrapulmonary TB (EPTB, 17 cases), and tuberculous pleurisy (TP, 20 cases). The sensitivity of Xpert in detecting PTB, EPTB, and TP was 88.5, 76.5, and 15.0%, respectively, which was slightly lower than IGRA (96.2, 82.4, and 95.0%, respectively), but higher than AFB (36.5, 11.8, and 0%, respectively); IGRA showed the highest sensitivity, but its specificity (55.9, 67.1, and 45.2%, respectively) was significantly lower than Xpert (99.6, 99.4, and 100%, respectively) and AFB (99.0, 99.4, and 100%, respectively) (P < 0.001). The sensitivity of Xpert in detecting lung tissue, cerebrospinal fluid, lymph nodes, and joint fluid was 100%, followed by sputum (88.5%), alveolar lavage (85.7%), and bronchoscopy secretion (81.2%); the pleural fluid sensitivity was the lowest, only 15.0%. For AFB negative patients, the sensitivity of Xpert in detecting PTB, EPTB, and TP was 84.9, 73.3, and 15.0%, respectively.

CONCLUSIONS

Xpert showed both high sensitivity and high specificity, and suggested its high value in TB diagnosis; however, the application of pleural fluid is still limited, and should be improved. Owing to the high sensitivity of IGRA, it is recommended for use as a supplementary test, especially for assisting in the diagnosis of TP and EPTB.

Diagnosis of extrapulmonary tuberculosis using the MPT64 antigen detection test in a high-income low tuberculosis prevalence setting

BACKGROUND

Extrapulmonary tuberculosis (EPTB) poses diagnostic challenges due to the paucibacillary nature of the disease. The immunochemistry-based MPT64 antigen detection test (MPT64 test) has shown promising results for diagnosing EPTB in previous studies performed in low-resource settings, with higher sensitivity than microscopy and culture. The aim of this study was to investigate the performance of the MPT64 test in a routine clinical setting in a high-income low TB prevalence country.

METHODS

Extrapulmonary samples sent for TB diagnostics to microbiology and pathology laboratories at three regional tertiary care hospitals in Norway in a one-year period were included and subjected to the MPT64 test in parallel to the routine TB diagnostic tests.

RESULTS

Samples from 288 patients were included and categorised as confirmed TB cases (n = 26), clinically diagnosed TB cases (n = 5), non-TB cases (n = 243) and uncategorised (n = 14), using a composite reference standard (CRS). In formalin-fixed biopsies, the sensitivity (95% CI) of the MPT64 test, microscopy, PCR-based tests pooled, and culture was 37% (16-62), 20% (4-48), 37% (16-62) and 50% (23-77), respectively, against the CRS. The MPT64 test showed a good positive predictive value (88%) and an excellent specificity (99, 95% CI 92-100) in formalin-fixed biopsies. In fine-needle aspirates, pus and fluid samples, the test performance was lower.

CONCLUSIONS

The MPT64 test was implementable in pathology laboratories as part of routine diagnostics, and although the sensitivity of the MPT64 test was not better than culture in this setting, the test supplements other rapid diagnostic methods, including microscopy and PCR-based tests, and can contribute to strengthen the diagnosis of EPTB in formalin-fixed biopsies in the absence of culture confirmation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Epidemiology of Extrapulmonary Tuberculosis among Inpatients, China, 2008-2017

We investigated the epidemiology of extrapulmonary tuberculosis (TB) among patients admitted to Beijing Chest Hospital, Beijing, China, during January 2008-December 2017. Of 19,279 hospitalized TB patients, 33.4% (6,433) had extrapulmonary TB and 66.6% (12,846) had pulmonary TB. The most frequent forms of extrapulmonary TB observed were skeletal TB (41.1%) and pleural TB (26.0%). Younger, female patients from rural areas were more likely to have extrapulmonary TB. However, patients with diabetes mellitus were less likely to have extrapulmonary TB compared with patients without diabetes. A higher proportion of multidrug-resistant (MDR) TB was observed among patients with extrapulmonary TB than among patients with pulmonary TB. We observed a large increase in MDR TB, from 17.3% to 35.7%, for pleural TB cases. The increasing rate of drug resistance among extrapulmonary TB cases highlights the need for drug susceptibility testing and the formulation of more effective regimens for extrapulmonary TB treatment.

Treatment outcomes and risk factors of extra-pulmonary tuberculosis in patients with co-morbidities

Background

Extra-pulmonary tuberculosis (EPTB) represents about 14% of all cases of tuberculosis (TB) in Malaysia. The aims of the study include evaluation of socio-demographic factors, clinical manifestations, co-morbidities among patients with EPTB and their treatment outcomes.

Methods

A retrospective study was conducted to recognize the epidemiology facts of EPTB. Individual data for EPTB patients were collected from TB registers, laboratory TB registers, treatment cards and TB medical personal files into a standardized study questionnaire. Crude (COR) and adjusted odds ratios (AOR) and 95% confidence intervals (CI) were determined to assess the risk factors for EPTB and unsuccessful treatment outcomes.

Results

There were 1222 EPTB patients presenting 13.1% of all TB cases during 2006–2008. Pleural effusion and lymph node TB were the most frequent types and accounted for 45.1% of all EPTB cases among study participants. Treatment success rate was 67.6%. The best treatment completion rates were found in children ≤15 years (0.478 [0.231–1.028]; p = 0.05). On multivariate analysis, age group 56–65 years (1.658 [1.157–2.376]; p = 0.006), relapse cases (7.078 [1.585–31.613]; p = 0.010), EPTB-DM (1.773 [1.165–2.698]; p = 0.008), patients with no formal (2.266 [1.254–4.095]; p = 0.001) and secondary level of education (1.889 [1.085–3.288]; p = 0.025) were recorded as statistically positive significant risk factors for unsuccessful treatment outcomes. Patients at the risk of EPTB were more likely to be females (1.524 [1.311–1.746]; p <  0.001), Malays (1.251 [1.056–1.482]; p = 0.010) and Indians (1.450 [1.142–1.842]; p = 0.002), TB-HIV (3.215 [2.347–4.405]; p <  0.001), EPDM-HIV (4.361 [1.657–11.474]; p = 0.003), EPTB-HIV-HEP (4.083 [2.785–5.987]; p <  0.001), those living in urban areas (1.272 [1.109–1.459]; p = 0.001) and no formal education (1.361 [1.018–1.820]; p = 0.037).

Conclusion

The findings of this study extend the knowledge of EPTB epidemiology and highlight the need for improved EPTB detection in Malaysia, especially in subpopulations with high risk for EPTB and unsuccessful treatment outcomes.

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.

Pulmonary Versus Extrapulmonary Tuberculosis Associated Factors: A Case-Case Study

BACKGROUND

Tuberculosis (TB) incidence remains low in health departments of Castellon and La Plana-Vila-real, but TB elimination is challenging. The objective of this study was to estimate associated factors of pulmonary tuberculosis (PTB) compared with extrapulmonary tuberculosis (ETB) and investigate epidemiological characteristics of these pathologies to orient control and prevention actions.

MATERIALS AND METHODS

A prospective case-case study was implemented by comparing PTB and ETB incidences during 2013-2016 from notification reports, epidemiological surveillance, and microbiological results of hospitals' laboratories Hospital General Castellon and La Plana-Vila-Real in the province of Castellon of Valencia region in Spain. In this design, cases were patients with PTB and controls were patients with ETB. Directed acyclic graph approach was used for selection of potential risk and confounding factors. Adjusted odds ratios (AORs) were estimated by logistic regression models.

RESULTS

The study included 136 patients with PTB and 57 patients with ETB, with microbiological confirmation of 93.4% and 52.6%, and the annual median of incidence rates were 7.5 and 3.1 per 100 000 inhabitants, respectively. In general, patients with PTB were younger with higher male proportion than patients with ETB. Risk factors of PTB were smoking tobacco (AOR = 3.98; 95% confidence interval [CI] = 1.66-9.56), social problems (social marginalization, homeless, residence in shelters for the poor, or stay in prison) (AOR = 3.39; 95% CI = 1.05-10.94), and contact with patients with TB (AOR = 2.51; 95% CI = 1.06-5.95). No-smoking tobacco and no-drug abuse interaction decrease PTB risk (AOR = 0.27; 95% CI = 0.12-0.64). From these results, specific measures of health promotion and prevention can be addressed.

CONCLUSIONS

The estimated associated factors of PTB may be prevented, and it was demonstrated that the case-case design is useful in the study of TB.

Musculoskeletal manifestations of tuberculosis: An observational study

Background:

Data of musculoskeletal manifestations of tuberculosis (TB) are limited to case reports, series, or retrospective studies. Therefore, we conducted this study to create awareness among doctors about musculoskeletal manifestations of TB.

Materials and Methods:

This was a prospective observational study conducted at a referral TB Hospital in North India in September and October 2016. The aim of our study was to study musculoskeletal manifestations of TB. We included patients who had active TB as per the World Health Organization 2010 criteria. Patients with other chronic illnesses were excluded. A detailed history, examination, and appropriate investigations (blood, urine, serological, and radiological) of the 100 consecutive patients fulfilling the inclusion criteria were recorded.

Results:

The mean age of patients was 32.16 ± 12.93 years. Male-to-female ratio was 43:57. The mean duration of disease was 6.85 ± 8.83 months. Of the 100 patients, 60 (60%) had pulmonary TB. The mean duration of antitubercular therapy was 1.79 ± 1.34 months. Fibromyalgia was classified in 21 (21%) patients, polyarthralgia was seen in 9 (9%), Pott's spine in 7 (7%), osteomyelitis in 4 (4%), and scleritis in 2 (2%) patients. Uveitis, tenosynovitis, erythema induratum, subcutaneous abscess, and dactylitis were seen in 1 (1%) patient each. In 21 patients who had fibromyalgia, 11 developed fibromyalgia with the second episode of TB amounting to 60.75% patients.

Conclusion:

This is the first prospective study to look at the musculoskeletal manifestations of TB. Patients with active TB were found to have various rheumatological manifestations.

Determinants of site of tuberculosis disease: An analysis of European surveillance data from 2003 to 2014

Background

We explored host-related factors associated with the site of tuberculosis (TB) disease using variables routinely collected by the 31 EU/EEA countries for national surveillance.

Methods

Logistic regression models were fitted to case-based surveillance data reported to the European Centre for Disease Prevention and Control for TB cases notified from 2003 to 2014. Missing data on HIV infection and on susceptibility to isoniazid and rifampicin for many patients precluded the inclusion of these variables in the analysis. Records from Finland, Lithuania, Spain and the United Kingdom were excluded for lack of exact details of disease localisation; other records without one or more variable (e.g. previous treatment history, geographical origin) or who had mixed pulmonary and extrapulmonary disease or more than one form of extrapulmonary disease were also removed (total exclusion = 38% of 913,637 notifications).

Results

564,916 TB cases reported by 27 EU/EEA countries had exclusive pulmonary (PTB; 83%) or extrapulmonary (EPTB; 17%) disease. EPTB was associated with age <15 years (aOR: 5.50), female sex (aOR: 1.60), no previous TB treatment (aOR: 3.10), and geographic origin (aOR range: 0.52–3.74). Origin from the Indian subcontinent or Africa was most strongly associated with lymphatic, osteo-articular and peritoneal/digestive localization (aOR>3.7), and age <15 years with lymphatic (aOR: 17.96) and central nervous system disease (aOR: 11.41).

Conclusions

Awareness of host-related determinants of site of TB is useful for diagnosis. The predilection for EPTB among patients originating from countries outside Europe may reflect strain preferences for disease localization, geographic/ethnic differences in disease manifestation and other factors, like HIV.

The changing epidemiology of spinal tuberculosis: the influence of international immigration in Catalonia, 1993-2014

The overall incidence of spinal tuberculosis (TB) appears to be stable or declining in most European countries, but with an increasing proportion of cases in the foreign-born populations. We performed a retrospective observational study (1993-2014), including all cases of spinal TB diagnosed at a Barcelona hospital to assess the epidemiological changes. Fifty-four episodes (48·1% males, median age 52 years) of spinal TB were diagnosed. The percentage of foreign-born residents with spinal TB increased from 14% to 45·2% in the last 10 years (P = 0·017). Positive Mycobacterium tuberculosis testing in vertebral specimens was 88·2% (15/17) for GeneXpert MTB/RIF. Compared with natives, foreign-born patients were younger (P < 0·01) and required surgery more often (P = 0·003) because of higher percentages of paravertebral abscess (P = 0·038), cord compression (P = 0·05), and persistent neurological sequelae (P = 0·05). In our setting, one-third of spinal TB cases occurred in non-native residents. Compared with natives, foreign-born patients were younger and had greater severity of the disease. The GeneXpert MTB/RIF test may be of value for diagnosing spinal TB.

Analysis of extrapulmonary tuberculosis in Spain: 2007-2012 National Study

INTRODUCTION

This study sought to study the epidemiological characteristics of the extrapulmonary tuberculosis (EPTB) in relation to pulmonary tuberculosis (PTB) from 2007 to 2012 in Spain, and plot its trend across the same period.

METHODS

We conducted an analytical cross-sectional study in which the following variables were analysed: age; sex; disease site; history of antituberculosis treatment; country of birth; presence of HIV infection; and culture results. Age-related differences were ascertained using the test of comparison of proportions, and crude and adjusted ORs were calculated using linear regression models.

RESULTS

Of the total of 44,050 cases of tuberculosis reported in the period 2007-2012 and included in the study, 31,508 (71.53%) were pulmonary tuberculosis and 12,542 (28.47%) were EPTB. EPTB rates decreased across all age groups. The main EPTB risk factor was presence of HIV infection (OR 1.39). Persons aged under 65 years had a lower risk of EPTB.

CONCLUSIONS

Although persons aged over 65 years displayed the highest incidence, there was nevertheless a downward trend across all age groups. Whereas children showed a significant decrease in tuberculous meningitis, this was not so for all extrapulmonary forms. EPTB rates among persons born outside Spain were much higher than those among the Spanish population.

Assessment of Extrapulmonary Tuberculosis in Two Provinces of Turkey

BACKGROUND

Tuberculosis (TB) is one of the main health issues in Turkey. Extrapulmonary TB cases have significant proportion comparing pulmonary TB cases. The aim of the study was to evaluate the extrapulmonary tuberculosis (EPTB) cases in two regions of Turkey, which have different demographic and socioeconomic characteristics.

METHODS

In this retrospective cohort study, EPTB cases between 2000 and 2005 in Van and Izmir Provinces of Turkey were analyzed and compared for symptoms, age groups, vaccination status, diagnostic procedures and social-economical conditions within two provinces. Descriptive analytic methods were used.

RESULTS

Total of 397 EPTB cases were reviewed retrospectively in Izmir and Van provinces. Pleural TB was most often seen EPTB form (47.6% vs. 32.6%) and female/male ratio was similar in both groups. Patients were in older ages in Izmir Province. Chest pain (20% vs. 32%), cough (33% vs. 26%) and night sweatiness (29% vs. 36%) were leading complaints. Low BCG vaccination rate and higher childhood EPTB were found in Van group, in contrary elderly EPTB was more often in of Izmir group.

CONCLUSION

Frequency of severe forms of EPTB is more often in younger ages in lower social economical condition areas.

Genotypic characterization and historical perspective of Mycobacterium tuberculosis among older and younger Finns, 2008-2011

The Mycobacterium tuberculosis genotypes obtained from elderly Finns were assessed and compared with those obtained from younger Finns to comprehend the epidemiology of tuberculosis (TB) in Finland. From 2008 to 2011, a total of 1021 M. tuberculosis isolates were characterized by spoligotyping and 15-locus mycobacterial interspersed repetitive units-variable number tandem repeat typing. In total, 733 Finnish-born cases were included in the study, of which 466 (64%) were born before 1945 (older Finns). Of these, 63 (14%) shared an M. tuberculosis genotype with foreign-born or younger Finnish cases (born after 1945), and 59 (13%) shared a genotype with older Finnish cases. Eighty-five per cent had a unique genotypic profile while 70% belonged to T or Haarlem families, suggesting that ongoing transmission is infrequent among young and elderly Finns. Simultaneous reactivation of TB among older Finns was the most likely cause for clustering. As most isolates belonged to Haarlem or T, Finland was most likely affected by a similar TB epidemic at the beginning of the twentieth century as that seen in Sweden and Norway. Younger Finns were significantly more likely to be clustered (56% versus 27%, p<0.001), have pulmonary TB (87% versus 71%, p<0.001) and to be sputum smear positive (57% versus 48%, p<0.05) indicating that the risk of TB transmission from younger Finns is likely to be larger than from older Finns. The M. tuberculosis isolates from elderly Finns were associated with dominant lineages of the early twentieth century and differed from the heterogeneous lineages found among younger TB patients. Additionally, younger TB patients were more likely to transmit TB than elderly Finns.

Mapping the epidemiology and trends of extra-pulmonary tuberculosis in Saudi Arabia

An extra-pulmonary tuberculosis (EPTB) infection rate of 30% in Saudi Arabia remains above the global rate. A variable rate of infection in each province has been reported and the involvement of most organs has been cited. Nationwide collective data on the current trends of infection are scarce and the factors behind the increased rate of EPTB are perplexing. This review endeavors to shed light into the epidemiology of EPTB, various types of infections sites, geographical differences in the infection rate, known risk factors, and challenges in the diagnosis and management of EPTB in Saudi Arabia.

Exploring the sociodemographic and clinical features of extrapulmonary tuberculosis in Saudi Arabia

Background

Saudi Arabia annually reports a relatively higher proportion (28–32%) of extrapulmonary tuberculosis (EPTB) cases in comparison to other global regions. However, there were few studies conducted so far to determine the sociodemographic factors and clinical manifestations associated with EPTB at a nationwide level.

Methodology

A retrospective analysis on culture positive EPTB isolates collected from all the provinces of the country were conducted for a period of 12 months to determine the spectrum of diversity in EPTB infection sites and the confounding factors. A detailed clinical and demographical data analysis was carried out along with first line drug susceptibility testing.

Principal Findings

Intra-thoracic and extra-thoracic lymph nodes (44.6%) were the most common sites of infection followed by gastrointestinal (17.3%) and central nervous systems (11.8%). Male patients were mostly infected (58.8%), in contrary to the global trend. Any drug resistance was observed in 23.1% isolates with a 2.1% of multi-drug resistance. HIV reactivity was found only in 2.2% cases. A higher proportion of Saudi nationals (58.8%) were infected compared to the immigrants, descending mostly from South Asia (34.4%) and South East Asia (31.2%). The Saudi population predominated with all forms of EPTB while immigrants showed no significant variations.

Conclusions

Saudi Arabia faces a serious threat from EPTB, particularly to the central nervous system and gastrointestinal systems. More effective diagnostic strategies and control measures must be implemented to reduce the high rate of EPTB in the country. In addition, these findings warrant further detailed research to explore all related comorbid conditions of EPTB development, particularly the host-related factors.

Primary Gingival Tuberculosis Diagnosed Based on Genetic Identification

A case of primary gingival tuberculosis in a 71-year-old Japanese woman is herein presented. A serous saliva culture was positive for tuberculosis, and we recognized that the origin of the tuberculosis infection was the gingiva based on the genetic identification in gingival biopsy tissue. The definitive diagnosis was facilitated by the genetic identification, a useful modern tool for diagnosing infectious diseases. The location and clinical presentation of this lesion were unusual, which underlines the importance of considering tuberculosis in the differential diagnosis of oral lesions that affect the gingiva.

Tuberculosis among migrant populations in the European Union and the European Economic Area

Background: Although tuberculosis (TB) incidence has been decreasing in the European Union/European Economic Area (EU/EEA) in the last decades, specific subgroups of the population, such as migrants, remain at high risk of TB. This study is based on the report ‘Key Infectious Diseases in Migrant Populations in the EU/EEA’ commissioned by The European Centre for Disease Prevention and Control. Methods: We collected, critically appraised and summarized the available evidence on the TB burden in migrants in the EU/EEA. Data were collected through: (i) a comprehensive literature review; (ii) analysis of data from The European Surveillance System (TESSy) and (iii) evidence provided by TB experts during an infectious disease workshop in 2012. Results: In 2010, of the 73 996 TB cases notified in the EU/EEA, 25% were of foreign origin. The overall decrease of TB cases observed in recent years has not been reflected in migrant populations. Foreign-born people with TB exhibit different socioeconomic and clinical characteristics than native sufferers. Conclusion: This is one of the first studies to use multiple data sources, including the largest available European database on infectious disease notifications, to assess the burden and provide a comprehensive description and analysis of specific TB features in migrants in the EU/EEA. Strengthened information about health determinants and factors for migrants’ vulnerability is needed to plan, implement and evaluate targeted TB care and control interventions for migrants in the EU/EEA.

Insight to the Epidemiology and Risk Factors of Extrapulmonary Tuberculosis in Tianjin, China during 2006-2011

BACKGROUND

The proportion of extrapulmonary tuberculosis (EPTB) among all the reported tuberculosis (TB) cases has increased in different populations. Despite the large burden of TB in China, the epidemiology of EPTB in China remains largely understudied and the risk factors for having EPTB diagnosis in China have not been identified.

METHODS

To gain insight to EPTB epidemiology in China, we analyzed TB surveillance data collected in Tianjin, China, during 2006 to 2011. The frequency of EPTB among all TB cases and within different socio-demographic groups of the study patients aged 15 years and older was determined for EPTB in general and by specific types. The distribution of socio-demographic characteristics was compared between pulmonary TB (PTB) group and EPTB group by chi-square test. Crude and multiple logistic regression-derived adjusted odds ratios (aOR) and 95% confidence intervals (CI) were determined to assess the associations between having EPTB diagnosis and each individual explanatory variable in question.

RESULTS

About one-tenth (1,512/14,561) of the patients investigated in this study had EPTB. Of these 1,512 EPTB cases, about two thirds were pleural TB. Significant difference in age, occupation, and urbanity of residence were found between PTB and EPTB groups (p<0.05). Patients with EPTB diagnosis were more likely to be 65 years or older (aOR = 1.22, 95% CI: 1.02, 1.46), to be retired (aOR = 1.37, 95% CI: 1.08, 1.75), and to live in urban areas (aOR = 1 38, 95% CI: 1.22, 1.55).

CONCLUSIONS

The findings of this study extends the knowledgebase of EPTB epidemiology in developing countries and highlight the need for improved EPTB detection in China, especially in subpopulations with high risk for EPTB or having limited access to medical facilities with adequate capacity for EPTB diagnosis.

[Investigation and management of genito-urinary tuberculosis]

Genito-urinary tuberculosis is the fourth most common manifestation of the disease, but it is often underestimated by clinicians because of few and non-specific symptoms and insidious disease course. The most common urinary findings are multiple ureteral stenosis. The most common genital involvement is an epididymal nodule for men and a chronic salpingitis for women. The definite diagnosis of genito-urinary tuberculosis is obtained on the basis of culture studies. Due to the paucibacillary nature of the disease, especially of genital location in woman, a probable or presumptive diagnosis is frequently considered with several parameters including radiological imaging (abdominal CT-scan, pelvic ultrasound, pelvic MRI). Endoscopic and surgical procedures are frequently required to obtain specimens for histopathologic and bacteriological studies. Medical treatment is the method of choice, with a combination of four drugs, namely isoniazid, rifampicin, ethambutol and pyrazinamide, followed by a two-drug regimen, for a total of six month duration. Surgery might be indicated in complicated genito-urinary tuberculosis (decreased renal function, infertility, urologic complaints).

A child presenting with tuberculous spondylitis in a single third cervical vertebra: a case report

INTRODUCTION

Despite a global reduction in tuberculosis, extrapulmonary tuberculosis is increasing. Spinal tuberculosis remains the commonest form of skeletal tuberculosis. Cervical spine involvement is rare but is the most dangerous form because of diagnostic difficulties and serious residual disability. We report a child who had single vertebral involvement of her third cervical vertebra which is extremely rare. To the best of our knowledge isolated third cervical vertebra involvement in a child by tuberculosis has not been reported previously. Difficulties in obtaining material for histology and bacterial culture from this critical location and how the diagnosis was reached despite these challenges are highlighted.

CASE PRESENTATION

A 10-year-old Sinhalese girl developed painful torticollis and 'cries during sleep'. She had received Bacillus Calmette-Guérin vaccine at birth, was well nourished, and had no loss of weight, anorexia or contact with tuberculosis. A plain radiograph of her neck showed a collapsed third cervical vertebra with no disc involvement. Magnetic resonance imaging confirmed isolated destruction of third cervical vertebra associated with prevertebral soft tissue swelling indenting the thecal sac without cord compression. Her chest radiograph was normal. There was peripheral lymphocytosis, elevated erythrocyte sedimentation rate, negative tuberculin (Mantoux) test, and negative QuantiFERON®-TB GoldIn-Tube assay. Invasive procedures to obtain tissue for histology, smear or culture were perceived by parents as dangerous due to surrounding critical structures and consent was denied. The differential diagnosis included spinal tuberculosis and unifocal Langerhan cell histiocytosis. Nocturnal symptoms and the prevertebral collection of soft tissue ('cold abscess') were characteristic of tuberculosis, and nonspecific findings of elevated erythrocyte sedimentation rate and lymphocytosis supported this diagnosis. An incidental finding of a calcified hepatic nodule when evaluating for multifocal histiocytosis was presumed to be tuberculous because schistosomiasis and visceral leishmaniasis were extremely rare in her country of residence, Sri Lanka. Empirical treatment with a 12-month course of antitubercular therapy resulted in clinical recovery and radiological healing. There was no kyphosis or neurological sequel.

CONCLUSIONS

This report highlights to clinicians the value of a high index of suspicion and careful history taking in spinal tuberculosis; and how a combination of nonspecific findings helped reach a clinicoradiological diagnosis.

National profile and treatment outcomes of patients with extrapulmonary tuberculosis in Bénin

BACKGROUND

In sub-Saharan Africa, there is a dearth of published literature on extrapulmonary tuberculosis (EPTB).

OBJECTIVE

To describe demographic, diagnostic and HIV-status characteristics of patients with EPTB in Bénin, their treatment outcomes, and among those who completed their treatment in the Centre National Hospitalier de Pneumo-Phtisiologie (CNHP-P), the proportion whose bodyweight increased during treatment.

MATERIAL AND FINDINGS

This was a retrospective cohort study with comparisons made between EPTB and new smear-positive pulmonary tuberculosis (NPTB) patients diagnosed in the country from January to December 2011. There were 383 EPTB patients (9% of all TB cases) with a mean age of 35 years, male/female ratio of 1.3 and important regional variation. There were significantly more females (p = 0.001), children <15 years (p<0.001) and HIV-positive patients (p = 0.005) with EPTB compared with NPTB. Pleural effusion, spinal and lymph node tuberculosis accounted for 66% of all EPTB. Children <15 years represented 16% of cases, with lymph node disease being most common among them (p<0.001). Of 130 EPTB patients registered in CNHP-P, 7% had a confirmed bacteriological/histological diagnosis. There were 331 (86%) patients who successfully completed treatment. More patients with EPTB were lost-to-follow-up compared with NPTB (p<0.001) with all these patients from one region. The best treatment completion rates were in children <15 years (OR:3.5, 95%CI:1.0-14.8) while patients with pleural effusion and ascites had the worst outcomes. Of 72 HIV-coinfected patients, 88% were on antiretroviral therapy (ART). HIV-positive status was associated with poor outcomes while those on ART fared better. In the CNHP-P, more than 80% who completed their treatment showed an increase in bodyweight and this was more evident in HIV-positive compared with HIV-negative patients (p = 0.03).

CONCLUSION

Patients with EPTB generally do well in Bénin, although the TB Programme would benefit through more attention to accurate diagnosis and earlier start of ART in HIV-infected patients.

[Epidemiology of hospitalizations for tuberculosis in Spain: analysis of minimum data set 1999-2009]

INTRODUCTION

The National Hospital Discharge Registry is a clinical-administrative database on hospital discharges, which is very useful at a regional level as a complementary source for surveillance. There are few national studies on tuberculosis (TB) using the National Hospital Discharge Registry, thus it was considered of interest to study the characteristics and trends of hospital discharges for TB in Spain.

METHODS

A descriptive study was performed using the main variables in the National Hospital Discharge Registry (sex, age, main diagnosis, type of discharge, length of stay), and trend analysis of hospitalization rates per 100,000 population, as well as primary diagnosis, by sex, age group, and type of TB (pulmonary [TBP]/extrapulmonary [TBEP]), for the period 1999-2009 in Spain.

RESULTS

A total of 65,609 hospital discharges were included in the study (66% male, 66% TBP, and 52% between 15-44 years). The overall rate of TB for the entire hospitalization period was 13.93 per 100,000 inhabitants, being 18.83 in males and 9.18 in females. The hospitalization rates for TBP and TBEP decreased in the period 1999-2009 in both sexes (TBP in males, from 18 to 13, and in females, from 8 to 6; TBEP in males from 4 to 3, and from 3 to 2 in female hospitalizations/100,000 habitants). In TBP, children are those with a smallest decline, and in TBEP there is an increase in males in all age groups from 2005.

CONCLUSIONS

The results are consistent with those from surveillance. The slow decline in rates in children and the increase in extrapulmonary forms in males may be related to immigration, so it is necessary to improve TB monitoring in these groups.

Influence of migration on tuberculosis in a semi-urban area

AIMS

To describe the epidemiology of tuberculosis and analyzing the differences among native and immigrant patients in Area III of the Region of Murcia.

METHODS

Cohort study of tuberculosis cases reported to the Epidemiological Surveillance Service from 2004 to 2009. Data collection was performed through the System of Notification Diseases, reviewing clinical files and epidemiological surveys.

RESULTS

One hundred sixty two cases were detected; 110 (67.9%) were immigrants, whose incidence rates ranged from 43.4 to 101.2 cases per 100,000 inhabitants. Ecuador (42.7%), Bolivia (30%) and Morocco (18.2%) were the main nationalities. Immigrants were younger than Spanish population (P<.001). The overall diagnostic delay was 50.5 days: 59.5 in Spanish and 47 in foreigners. Moroccans had higher proportions of extrapulmonary TB (P=.02). Mainly, immigrant population took treatment with four drugs (P<.001). Natives had better treatment adherence (P=.04). Spanish cases tuberculosis were associated with smoking (P<.001), the same as alcohol consumption (P=.01) and injection drug use (P<.001), nevertheless in the foreign-born population the most relevant risk factor was overcrowding (P<.001).

CONCLUSIONS

The incidence tuberculosis rates are higher among immigrant population, whose the main risk factor is overcrowding. In contrast, Spanish cases are associated with toxic substances consumption and increasing age.

Comparative clinical study of different multiplex real time PCR strategies for the simultaneous differential diagnosis between extrapulmonary tuberculosis and focal complications of brucellosis

BACKGROUND

Both brucellosis and tuberculosis are chronic-debilitating systemic granulomatous diseases with a high incidence in many countries in Africa, Central and South America, the Middle East and the Indian subcontinent. Certain focal complications of brucellosis and extrapulmonary tuberculosis are very difficult to differentiate clinically, biologically and radiologically. As the conventional microbiological methods for the diagnosis of the two diseases have many limitations, as well as being time-consuming, multiplex real time PCR (M RT-PCR) could be a promising and practical approach to hasten the differential diagnosis and improve prognosis.

METHODOLOGY/PRINCIPAL FINDINGS

We designed a SYBR Green single-tube multiplex real-time PCR protocol targeting bcsp31 and the IS711 sequence detecting all pathogenic species and biovars of Brucella genus, the IS6110 sequence detecting Mycobacterium genus, and the intergenic region senX3-regX3 specifically detecting Mycobacterium tuberculosis complex. The diagnostic yield of the M RT-PCR with the three pairs of resultant amplicons was then analyzed in 91 clinical samples corresponding to 30 patients with focal complications of brucellosis, 24 patients with extrapulmonary tuberculosis, and 36 patients (Control Group) with different infectious, autoimmune or neoplastic diseases. Thirty-five patients had vertebral osteomyelitis, 21 subacute or chronic meningitis or meningoencephalitis, 13 liver or splenic abscess, eight orchiepididymitis, seven subacute or chronic arthritis, and the remaining seven samples were from different locations. Of the three pairs of amplicons (senX3-regX3+ bcsp3, senX3-regX3+ IS711 and IS6110+ IS711) only senX3-regX3+ IS711 was 100% specific for both the Brucella genus and M. tuberculosis complex. For all the clinical samples studied, the overall sensitivity, specificity, and positive and negative predictive values of the M RT-PCR assay were 89.1%, 100%, 85.7% and 100%, respectively, with an accuracy of 93.4%, (95% CI, 88.3-96.5%).

CONCLUSIONS/SIGNIFICANCE

In this study, a M RT-PCR strategy with species-specific primers based on senX3-regX3+IS711 sequences proved to be a sensitive and specific test, useful for the highly efficient detection of M. tuberculosis and Brucella spp in very different clinical samples. It thus represents an advance in the differential diagnosis between some forms of extrapulmonary tuberculosis and focal complications of brucellosis.

Tuberculosis transmission among immigrants and autochthonous populations of the eastern province of Saudi Arabia

Background

Eastern province of Saudi Arabia is an industrial zone with large immigrant population and high level of tuberculosis case notification among immigrants. The impact of immigration and current trends of tuberculosis transmission among immigrants and autochthonous population in the region had not been investigated so far using molecular tools.

Methodology

During 2009- 2011, a total of 524 Mycobacterium tuberculosis isolates were collected from the central tuberculosis reference laboratory, representing an estimated 79.2% of the culture-positive tuberculosis cases over the study period in the province. These isolates were genotyped by using 24 locus-based MIRU-VNTR typing and spoligotyping followed by first line drug susceptibility testing. The molecular clustering profiles and phylogenetic diversity of isolates were determined and compared to the geographical origins of the patients.

Principle Findings

Genotyping showed an overall predominance of Delhi/CAS (29.4%), EAI (23.8%) and Ghana (13.3%) lineages, with slightly higher proportions of Delhi/CAS among autochthonous population (33.3 %) and EAI (30.9%) among immigrants. Rate of any drug resistance was 20.2% with 2.5% of multi-drug resistance. Strain cluster analysis indicated 42 clusters comprising 210 isolates, resulting in a calculated recent transmission index of 32.1%. Overall shared cluster ratio was 78.6% while 75.8% were shared between autochthonous population and immigrant population with a predominance of immigrants from South east Asia (40.7%). In contrast, cross national transmission within the immigrant population was limited (24.2%). Younger age (15-30- p value-0.043, 16-45, p value 0.030), Saudi nationality (p value-0.004) and South East Asian origin (p value-0.011) were identified as significant predisposing factors for molecular strain clustering.

Conclusions

The high proportion of molecular clusters shared among the autochthonous and immigrant populations suggests a high permeability of tuberculosis transmission between both populations in the province. These results prompt for the need to strengthen the current tuberculosis control strategies and surveillance programs.

Tuberculosis among Africans living in the United States, 2000-2009

The incidence of tuberculosis (TB) has declined steadily in the United States; however, foreign-born persons are disproportionately affected. The aim of our study was to describe characteristics of TB patients diagnosed in the United States who originated from the African continent. Using data from the U.S. National Tuberculosis Surveillance System, we calculated TB case rates and analyzed differences between foreign-born patients from Africa compared with other foreign-born and U.S.-born patients. The 2009 TB case rate among Africans (48.1/100,000) was 3 times as high as among other foreign-born and 27 times as high as among U.S.-born patients. Africans living in the United States have high rates of TB disease; they are more likely to be HIV-positive and to have extrapulmonary TB. Identification and treatment of latent TB infection, HIV testing and treatment, and a high index of suspicion for extrapulmonary TB are needed to better address TB in this population.

Molecular characterization of Mycobacterium tuberculosis isolates from North Indian patients with extrapulmonary tuberculosis

Genotypic studies are important to understand the molecular epidemiology and transmission routes of Mycobacterium tuberculosis. In the first and largest study from India, spoligotyping and 24 loci mycobacterial interspersed repetitive units (MIRU) were performed to find genetic profiles of 125 M. tuberculosis strains isolated from patients with extrapulmonary tuberculosis (EPTB) and their drug susceptibility test was performed using BACTEC-MGIT 960. Spoligotyping results were compared with the world Spoligotyping Database of Institute Pasteur de Guadeloupe (SpolDB4). The spoligotyping results showed that 110 (88%) displayed known patterns while 15 (12%) isolates had no matching database. Predominant spoligotypes belonged to CAS family (57.27%). The largest clade comprised of 38 isolates belonging to the CAS1_DEL lineage. Though there was no significant association between specific mycobacterial lineage and extrapulmonary site, a significantly high (p < 0.001) number of Beijing type isolates (28.6%) were isolated from bone and joint samples as compared to cerebrospinal fluid (5%). There was a significant association between Beijing family isolates and multi-drug-resistance, while all MANU genotypes were pan-drug sensitive. The CAS family lineage was most prevalent genotype in the EPTB cases in our population.

Meta-analysis: the association between HIV infection and extrapulmonary tuberculosis

BACKGROUND

Extrapulmonary tuberculosis has been an AIDS-defining condition. Individual studies that highlight the association between HIV and extrapulmonary TB are available. Our objectives were to synthesis evidence on the association between extrapulmonary tuberculosis and HIV and to explore the effective preventive measures of these two diseases.

METHODS

This is a meta-analysis of observational studies reporting effect estimates on how HIV is associated with extrapulmonary tuberculosis. We searched for the eligible studies in the electronic databases using search terms related to HIV and extrapulmonary tuberculosis. Where possible, we estimated the summary odds ratios using random effects meta-analysis. We stratified analysis by the type of study design. We assessed heterogeneity of effect estimates within each group of studies was assessed using I (2) test.

RESULTS

Nineteen studies (7 case control studies and 12 cohort studies) were identified for the present study. The pooled analysis shows a significant association between HIV and extrapulmonary tuberculosis (summary odds ratio: 1.3; 95 % confidence interval (CI) 1.05-1.6; I (2): 0 %). In a subgroup analysis with two studies, a significant association was found between CD4+ count less than 100 and the incidence of extrapulmonary tuberculosis (summary OR: 1.31; 95 % CI 1.02-1.68; I (2): 0 %).

CONCLUSIONS

Findings show evidence on the association between extrapulmonary tuberculosis and HIV, based on case control studies. Further studies to understand the mechanisms of interaction of the two pathogens are recommended.

Ethnicity and mycobacterial lineage as determinants of tuberculosis disease phenotype

BACKGROUND

Emerging evidence suggests that Mycobacterium tuberculosis (Mtb) lineage and host ethnicity can determine tuberculosis (TB) clinical disease patterns but their relative importance and interaction are unknown.

METHODS

We evaluated prospectively collected TB surveillance and Mtb strain typing data in an ethnically heterogeneous UK population. Lineage assignment was denoted using 15-loci mycobacterial interspersed repetitive units containing variable numbers of tandem repeats (MIRU-VNTR) and MIRU-VNTRplus. Geographical and ethnic associations of the six global Mtb lineages were identified and the influence of lineage and demographic factors on clinical phenotype were assessed using multivariate logistic regression.

RESULTS

Data were available for 1070 individuals with active TB which was pulmonary only, extrapulmonary only and concurrent pulmonary-extrapulmonary in 52.1%, 36.9% and 11.0% respectively. The most prevalent lineages were Euro-American (43.7%), East African Indian (30.2%), Indo-Oceanic (13.6%) and East Asian (12.2%) and were geo-ethnically restricted with, for example, Indian subcontinent ethnicity inversely associated with Euro-American lineage (OR 0.23; 95% CI 0.14 to 0.39) and positively associated with the East African-Indian lineage (OR 4.04; 95% CI 2.19 to 7.45). Disease phenotype was most strongly associated with ethnicity (OR for extrathoracic disease 21.14 (95% CI 6.08 to 73.48) for Indian subcontinent and 14.05 (3.97 to 49.65) for Afro-Caribbean), after adjusting for lineage. With East Asian lineage as the reference category, the Euro-American (OR 0.54; 95% CI 0.32 to 0.91) and East-African Indian (OR 0.50; 95% CI 0.29 to 0.86) lineages were negatively associated with extrathoracic disease, compared with pulmonary disease, after adjusting for ethnicity.

CONCLUSIONS

Ethnicity is a powerful determinant of clinical TB phenotype independently of mycobacterial lineage and the role of ethnicity-associated factors in pathogenesis warrants investigation.