Effect of Metformin on Plasma Exposure of Rifampicin, Isoniazid, and Pyrazinamide in Patients on Treatment for Pulmonary Tuberculosis

BACKGROUND

To evaluate the effect of metformin on the plasma levels of rifampicin, isoniazid, and pyrazinamide in patients with drug-sensitive pulmonary tuberculosis being treated with first-line antituberculosis treatment (ATT) and to assess the influence of gene polymorphisms on the metabolic pathway of metformin and plasma levels of antitubercular drugs.

METHODS

Nondiabetic adults aged 18-60 years with pulmonary tuberculosis were randomized to either the standard ATT (ATT group) or ATT plus metformin (METRIF group) groups in a phase IIB clinical trial. An intensive pharmacokinetic study with blood collection at 0 hour (predosing), followed by 1, 2, 4, 6, 8, and 12 hours after dosing was conducted during the first month of treatment in a subset of 60 study participants after a minimum of 14 doses. Plasma concentrations of rifampicin, isoniazid, pyrazinamide, and metformin were measured by high-performance liquid chromatography using validated methods, and pharmacokinetic parameters and OCT1 and MATE1 gene polymorphisms were compared between the groups.

RESULTS

Significant increases in the clearance of rifampicin, isoniazid, and pyrazinamide were observed in patients in the METRIF group (n = 29) compared with those in the ATT group (n = 31). The AA genotypes of the single-nucleotide polymorphism of rs2289669 ( MATE1 ) in the METRIF group showed a significantly decreased area under the concentration-time curve to the last observation point and increased clearance of rifampicin.

CONCLUSIONS

Metformin altered rifampicin and isoniazid plasma concentrations in patients receiving antituberculosis treatment for pulmonary tuberculosis with little effect on sputum conversion at the end of treatment. Studies with larger sample sizes are needed to understand host drug-drug interactions.

Phylogeny and evolution of SARS-CoV-2 during Delta and Omicron variant waves in India

SARS-CoV-2 evolution has continued to generate variants, responsible for new pandemic waves locally and globally. Varying disease presentation and severity has been ascribed to inherent variant characteristics and vaccine immunity. This study analyzed genomic data from 305 whole genome sequences from SARS-CoV-2 patients before and through the third wave in India. Delta variant was reported in patients without comorbidity (97%), while Omicron BA.2 was reported in patients with comorbidity (77%). Tissue adaptation studies brought forth higher propensity of Omicron variants to bronchial tissue than lung, contrary to observation in Delta variants from Delhi. Study of codon usage pattern distinguished the prevalent variants, clustering them separately, Omicron BA.2 isolated in February grouped away from December strains, and all BA.2 after December acquired a new mutation S959P in ORF1b (44.3% of BA.2 in the study) indicating ongoing evolution. Loss of critical spike mutations in Omicron BA.2 and gain of immune evasion mutations including G142D, reported in Delta but absent in BA.1, and S371F instead of S371L in BA.1 could explain very brief period of BA.1 in December 2021, followed by complete replacement by BA.2. Higher propensity of Omicron variants to bronchial tissue, probably ensured increased transmission while Omicron BA.2 became the prevalent variant possibly due to evolutionary trade-off. Virus evolution continues to shape the epidemic and its culmination.Communicated by Ramaswamy H. Sarma.

Comparative study on complications and difficulties in laparoscopy in female genital tuberculosis cases versus non-tuberculosis cases

BACKGROUND AND OBJECTIVE

Female genital tuberculosis (FGTB) is an important type of extrapulmonary tuberculosis (TB) associated with morbidity especially infertility in developing countries. Laparoscopy may be difficult and hazardous in FGTB. The aim of the study was to observe the difficulties and complications of laparoscopy in FGTB cases.

MATERIALS AND METHODS

It was a prospective study over 12 years' period on 412 cases of diagnostic laparoscopy performed on FGTB cases with infertility. All patients underwent history taking and clinical examination and endometrial sampling for acid-fast bacilli (AFB) microscopy, culture, polymerase chain reaction (PCR), gene Xpert (last 212 cases) and histopathological evidence of epithelioid granuloma. Another 412 cases of diagnostic laparoscopy in the absence of FGTB performed during same time were taken as controls from the pool of non-TB cases. Various difficulties and complications were noted in both groups and statistical analysis was done.

RESULTS

Mean age, parity, body mass index and duration of infertility were 26.8 versus 25.4 years, 0.32 versus 0.28, 23.15 versus 25.28 Kg/m 2 and 4.15 versus 5.12 years, respectively. Primary and secondary infertility was seen in 78.6% and 20.38% of cases in the study group and 74.75% and 25.24% in the control group, respectively. Endometrial biopsy showed AFB microscopy in 5.3%, culture in 6.3%, epithelioid granuloma in 15.77% and on peritoneal biopsy granuloma in 6.55%, positive PCR in 368 (89.32%) and positive gene Xpert in 38 out of 212 (17.92%, out of last 212 cases). Definite findings of FGTB were seen in 171 (41.50%) cases. Probable findings of FGTB were seen in 241 (58.49%) cases. Various complications were difficulty in the creation of pneumoperitoneum or insertion of trocar and cannula in 16.74% and 13.10% of cases as compared to 1.94% and 1.69% in the control group. Excessive bleeding was seen in 5.09% versus 0.97% cases, respectively. Various injuries observed were bowel injury in 1.69% versus 0.24% cases (small bowel in 1.21% vs. 0.24%, large bowel in 0.48% vs. 0.1%), while bladder injury was seen in 0.97% versus 0.24% cases, subacute intestinal obstruction was seen in 5.8% versus 0.72% cases respectively while flare up of TB was seen in 5.09% versus 0% in cases and controls, respectively. Wound infection was seen in 8.48% versus 1.25% cases, respectively.

INTERPRETATION AND CONCLUSION

FGTB is associated with increased complications and difficulties as compared to laparoscopy in other cases.

GeneXpert Ultra in Urine Samples for Diagnosis of Extra-Pulmonary Tuberculosis

Extra-pulmonary tuberculosis (EPTB) continues to be difficult to diagnose. Novel biomarkers in biological specimens offer promise. Detection of Mycobacterium tuberculosis (Mtb) DNA in urine could prove useful in diagnosis of EPTB, possibly due to disseminated disease or micro-abscesses reported in kidneys. The current study was designed to detect Mtb DNA in stored urine samples from patients with EPTB. Diagnosis of EPTB was reached using Microbiological Reference Standards (MRS) on samples from the disease site using WHO Recommended Diagnostics (WRD), [smear microscopy, liquid culture (MGIT-960)] and GX (molecular WRD, mWRD) and Comprehensive reference standards [CRS, clinical presentation, microbiological reference standards, radiology, histopathology]. GX-Ultra was performed on urine samples stored in -80oC deep freezer, retrospectively. Of 70 patients, 51 (72.9%) were classified as confirmed TB, 11 (15.7%) unconfirmed TB, and 8 (11.4%) unlikely TB. GX-Ultra in urine samples demonstrated sensitivity of 52.9% and specificity of 57.9% against MRS, and higher sensitivity of 56.5% and specificity of 100% against CRS. The sensitivity and specificity of GX-Ultra in urine was 53.6% and 75% for pus sample subset and 52.2% and 53.3% for fluid sample subset. Urine being non-invasive and easy to collect, detection of Mtb DNA using mWRD in urine samples is promising for diagnosis of EPTB.

A strip-based assay for detection of CrfA enzyme activity to differentiate Mycobacterium tuberculosis and non-tuberculous mycobacteria

There is an unmet need for tools that permit diagnosis of Tuberculosis (TB) that are affordable, low-tech, and can differentiate Mycobacterium tuberculosis (M.tb) from non-tuberculous mycobacteria (NTM). In this study, we have developed a strip-based assay to detect the activity of a unique Carbapenem Resistance Factor A (CrfA) enzyme present only in M.tb. The strip comprises of PVDF (Polyvinylidene fluoride) membrane that has an immobilized anti-CrfA antibody to capture the CrfA enzyme from M.tb lysate. Lysate of mycobacteria is applied to the strip, washed, and incubated in the presence of chromogenic reporter dye which is a substrate for CrfA. A change in the color of the dye that is readily visible to the naked eye is the readout. We evaluated lysates from M.tb and various NTMs namely, M. abscessus, M. chelonae, M. avium, M. obuense, M. paraintracellulare, M. kansasi, including the patient-derived sputum samples. The strip assay selectively identified only those samples containing M.tb. Based on this evidence, this new assay enables the identification and differentiation of M.tb from NTMs in patient sputum samples. As this tool can be simple to use, therefore has the potential to serve the unmet need for diagnosis of TB and NTM infections in resource-limited settings.

Expedited diagnosis of pediatric tuberculosis using Truenat MTB-Rif Dx and GeneXpert MTB/RIF

Rapid, cost-effective, and sensitive diagnostic assays are essential for global tuberculosis (TB) control, especially in high TB burden, resource-limited settings. The current study was designed to evaluate diagnostic accuracy of Truenat MTB-Rif Dx (MolBio) in children less than 18 years of age, with symptoms suggestive of TB. Gastric aspirate, induced sputum, and broncho-alveolar lavage samples were subjected simultaneously to AFB-smear, GeneXpert MTB/RIF, liquid culture (MGIT-960) and Truenat MTB-Rif Dx. The index-test results were evaluated against microbiological reference standards (MRS). Truenat MTB-Rif Dx had a sensitivity of 57.1%, specificity of 92% against MRS. The sensitivity and specificity of the Truenat MTB-RIF Dx compared with liquid culture was 58.7% and 87.5% while GeneXpert MTB/RIF was 56% and 91.4%. The performance of both GeneXpert MTB/RIF and Truenat MTB-Rif Dx are comparable. Result of our study demonstrates that Truenat MTB-Rif can aid in early and efficient diagnosis of TB in children.

Laparoscopic evaluation of female genital tuberculosis in infertility: An observational study

Background & objectives

Female genital tuberculosis (FGTB) is an important variety of extrapulmonary TB causing significant morbidity, especially infertility, in developing countries like India. The aim of this study was to evaluate the laparoscopic findings of the FGTB.

Methods

This was a cross-sectional study on 374 cases of diagnostic laparoscopy performed on FGTB cases with infertility. All patients underwent history taking and clinical examination and endometrial sampling/biopsy for acid-fast bacilli, microscopy, culture, PCR, GeneXpert (only last 167 cases) and histopathological evidence of epithelioid granuloma. Diagnostic laparoscopy was performed in all the cases to evaluate the findings of FGTB.

Results

Mean age, parity, body mass index and duration of infertility were 27.5 yr, 0.29, 22.6 kg/m² and 3.78 years, respectively. Primary infertility was found in 81 per cent and secondary infertility in 18.18 per cent of cases. Endometrial biopsy was positive for AFB microscopy in 4.8 per cent, culture in 6.4 per cent and epithelioid granuloma in 15.5 per cent. Positive peritoneal biopsy granuloma was seen in 5.88 per cent, PCR in 314 (83.95%) and GeneXpert in 31 (18.56%, out of last 167 cases) cases. Definite findings of FGTB were seen in 164 (43.86%) cases with beaded tubes (12.29%), tubercles (32.88%) and caseous nodules (14.96%). Probable findings of FGTB were seen in 210 (56.14%) cases with pelvic adhesions (23.52%), perihepatic adhesions (47.86%), shaggy areas (11.7%), pelvic adhesions (11.71%), encysted ascites (10.42%) and frozen pelvis in 3.7 per cent of cases.

Interpretation & conclusions

The finding of this study suggests that laparoscopy is a useful modality to diagnose FGTB with a higher pickup rate of cases. Hence it should be included as a part of composite reference standard.

An evaluation of Composite Reference Standard (CRS) for diagnosis of Female Genital Tuberculosis

BACKGROUND

Female genital tuberculosis (FGTB) is a common cause of infertility in developing countries. Its diagnosis is difficult due to its paucibacillary nature, with no single test having high sensitivity and specificity. This study is to share the experience of using Composite Reference Standard (CRS) for the diagnosis of FGTB.

METHODS

This is a prospective study conducted between September 2017 to June 2019, over 100 infertile females found to have FGTB on composite reference standard which consisted of acid-fast bacilli on microscopy or culture, histopathological evidence of epithelioid granuloma, positive gene Xpert on endometrial sample or definite or probable finding of FGTB on laparoscopy.

RESULTS

A total of 100 infertile women (78% primary, 22% secondary) found to have FGTB on CRS were enrolled in this study. Mean age, body mass index, parity and duration of infertility were 28.2 years, 23.17 kg/m², 0.24 ± 0.12 and 2.41 years respectively. Various symptoms were scanty menses (16%), irregular cycle (7%), dysmenorrhea (11%), pelvic pain (11%). Various signs were vaginal discharge (65%), adnexal mass (6%), tubo-ovarian mass on ultrasound (15%), abnormal hysterosalpingography findings (57.14%), positive polymerase chain reaction test (65%) and abnormal hysteroscopy (82.2%). The positive findings on CRS were positive AFB on microscopy or culture (3%), positive gene Xpert (28%) (done in some cases), epithelioid granuloma on histopathology (13%), definite findings on laparoscopy like tubercles, caseous nodules and beaded tubes in (57.19%) patients while probable findings of FGTB like straw colored fluid in POD, extensive dense pelvic, peri-tubal, peri-ovarian adhesions; hydrosalpinx; tubo-ovarian mass; thick fibrosed tubes; mid tubal block; peri hepatic adhesions (Fitz Hugh Curtis Syndrome); hyperemia of tubes/blue uterus on chromotubation were seen in (48.8%) patients. All patients found to be positive on CRS were given 6 months of anti-tubercular therapy.

CONCLUSION

This study demonstrates the high reliability of use of composite reference standard for diagnosis of FGTB.

Efficacy of Bacillus Calmette-Guérin (BCG) Vaccination in Reducing the Incidence and Severity of COVID-19 in High-Risk Population (BRIC): a Phase III, Multi-centre, Quadruple-Blind Randomised Control Trial

INTRODUCTION

Universal coverage of vaccines alone cannot be relied upon to protect at-risk populations in lower- and middle-income countries against the impact of the coronavirus disease 2019 (COVID-19) pandemic and newer variants. Live vaccines, including Bacillus Calmette-Guérin (BCG), are being studied for their effectiveness in reducing the incidence and severity of COVID-19 infection.

METHODS

In this multi-centre quadruple-blind, parallel assignment randomised control trial, 495 high-risk group adults (aged 18-60 years) were randomised into BCG and placebo arms and followed up for 9 months from the date of vaccination. The primary outcome was the difference in the incidence of COVID-19 infection at the end of 9 months. Secondary outcomes included the difference in the incidence of severe COVID-19 infections, hospitalisation rates, intensive care unit stay, oxygen requirement and mortality at the end of 9 months. The primary analysis was done on an intention-to-treat basis, while safety analysis was done per protocol.

RESULTS

There was no significant difference in the incidence rates of cartridge-based nucleic acid amplification test (CB-NAAT) positive COVID-19 infection [odds ratio (OR) 1.08, 95% confidence interval (CI) 0.54-2.14] in the two groups, but the BCG arm showed a statistically significant decrease in clinically diagnosed (symptomatic) probable COVID-19 infections (OR 0.38, 95% CI 0.20-0.72). Compared with the BCG arm, significantly more patients developed severe COVID-19 pneumonia (CB-NAAT positive) and required hospitalisation and oxygen in the placebo arm (six versus none; p = 0.03). One patient belonging to the placebo arm required intensive care unit (ICU) stay and died. BCG had a protective efficacy of 62% (95% CI 28-80%) for likely symptomatic COVID-19 infection.

CONCLUSIONS

BCG is protective in reducing the incidence of acute respiratory illness (probable symptomatic COVID-19 infection) and severity of the disease, including hospitalisation, in patients belonging to the high-risk group of COVID-19 infection, and the antibody response persists for quite a long time. A multi-centre study with a larger sample size will help to confirm the findings in this study.

CLINICAL TRIALS REGISTRY

Clinical Trials Registry India (CTRI/2020/07/026668).

Evaluation of implantation markers and immune cell infiltration in endometrial biopsy of female genital tuberculosis

BACKGROUND

Female genital tuberculosis (FGTB) causes infertility in a significant number of females. The immunological impact of tuberculosis on endometrium in infertile females has not been studied before. The present study was designed to evaluate markers related to infiltrating immune cells and implantation in endometrial aspiration from infertile females and correlate with conventional tests and polymerase chain reaction (PCR) for tuberculosis (TB).

METHODS

It was a prospective cohort study with 385 patients out of which IHC was done in 306 over a period of 3 years from 2013 to 2016 in a tertiary care hospital. Women with infertility, 20-35 years of age, without history of pulmonary TB or intake of antitubercular therapy were included. Endometrial samples were subjected to PCR for TB along with microbiological and histological examination for TB. Immunohistochemistry for CD45, CD3, CD20, CD4, CD8, CD68, CD138, Interferon gamma, Interleukin 10 (IL-10) and implantation markers MUC1 and Notch 1 were done on the endometrial samples along with 25 control subjects.

RESULTS

Conventional tests for tuberculosis like staining for acid fast bacilli (AFB), granuloma on histology or culture positivity were seen in 2.61% (6/306; 1.96% had granulomas, 1/306; 0.32% was AFB positive, 2/306; 0.6% were liquid culture positive). PCR was positive in 190/306 (62.09%). CD3, CD20, CD45, CD68, CD4, CD8 and CD 138 expressing infiltrating cells were not significantly related to PCR positive cases. Interferon gamma expressing lymphocytes were significantly higher (38.94%) in PCR positive endometria compared to 26.72% in the PCR negative (p = 0.04). Notch -1 expression correlated significantly with the occurrence of pregnancy. A trend towards high intensity expression of Notch1 was seen in PCR negative cases. MUC-1 expression did not correlate with pregnancy although interferon gamma expression was significantly related to low intensity MUC1 expression.

CONCLUSIONS

Immunohistochemical markers are not reliable tests in diagnosis of FGTB. Notch 1 expression though showing correlation with pregnancy has to be further evaluated with a panel of other implantation markers.

STUDY FUNDING

Indian Council of Medical Research, New Delhi, India.

Hysterosalpingography Observations in Female Genital Tuberculosis with Infertility

Background

Hysterosalpingography (HSG) is radiographic evaluation of uterine cavity and tubal patency.

Aims

The aim of this study was to evaluate the safety and utilisation of HSG in female genital tuberculosis (FGTB) with infertility.

Settings and Design

The study was conducted in a tertiary referral centre of North India.

Materials and Methods

It was a prospective study on 87 cases of FGTB with infertility. Diagnosis of FGTB was made by composite reference standard using the presence of acid-fast bacilli on microscopy/culture or positive GeneXpert, positive polymerase chain reaction or epithelioid granuloma on endometrial biopsy or definitive or probable findings on laparoscopy or hysteroscopy.

Statistical Analysis Used

Suitable statistical methods were used with STATA software version 12.0.

Results

HSG findings were normal in 49 (56.32%) cases. There were filling defects in 14 (16.09%), short and shrunken cavity in 4 (4.49%), intrauterine synechiae in 14 (16.09%), T-shaped cavity in 3 (3.44%) and deformed uterine cavity in 5 (5.74%) cases. Fallopian tube findings were hydrosalpinx in 12 (13.79%) and 11 (12.64%) cases, beading of tube in 4 (4.59%) and 2 (2.29%) cases, pipestem appearance in 2 (2.29%) cases each and Maltese cross appearance in 3 (3.44%) and 2 (2.29%) cases, respectively. Tubal blockage was seen in 69 (79.31%) and 67 (77.01%) cases being cornual block in 28 (32.18%) and 26 (29.88%) cases, mid-tubal block in 16 (18.39%) and 15 (17.24%) cases, multiple blocks in 10 (11.49%) and 12 (13.79%) cases and fimbrial block in 15 (17.24%) and 14 (16.09%) cases. None of the cases had flare-up of the disease after HSG in the current study.

Conclusion

HSG is a useful modality in FGTB with infertility.

Role of Magnetic Resonance Imaging in evaluation of tuberculous tubo ovarian mass

OBJECTIVE

Role of Magnetic Resonance Imaging (MRI) in diagnosis of tuberculous tubo-ovarian (TO) mass.

METHODS

MRI was performed on 33 patients of tuberculous TO mass of female genital tuberculosis (FGTB).

RESULTS

Mean age, BMI, and parity was 27.5 ± 4.2 years, 22.7 ± 3.6 kg/m², and 0.27 ± 0.13. All patients (100%) had infertility; primary infertility (72.72%) and secondary infertility (27.23%) with mean 5.8 years. Abdominal/pelvic pain 33 (100%) cases, abdominal lump 4 (12.12%), adnexal mass 33 (100%). MRI findings showed pelvic masses 33 (100%), bilateral TO masses 11 (33.33%), cystic lesion 4 (12.12%), solid cystic lesion 3 (9.09%) with bilateral pyosalpinx 1 (3.3%), homogeneous content with ascites 1 (3.03%), rim enhancing lesion abutting pelvic wall in 1 (3.03%). Right adnexal mass 11 (33.33%), right adnexal cyst 2 (6.06%), right adnexal cystic mass in 1 (3.03%), right sided complex TO mass 1 (3.03%), right sided hydrosalpinx in 1 (3.03%) case, right sided TO mass in 4 (12.12%) cases and right sided para-ovarian cyst in 2 (6.06%). Left sided adnexal mass was seen in 11 (33.33%), cystic lesion in 1 (3.03%), ovarian cyst in 3 (9.09%) cases, left sided hydrosalpinx in 2 (6.06%), left ovarian cyst 2 (6.06%) cases, left sided ovarian cyst with encysted ascites 1 (3.03%) case and with left sided paraovarian cyst 2 (6.06%) case. Miscellaneous finding were generalised ascites (6.06%), encysted ascites (3.03%), pelvic (1; 3.03%) and mesenteric lymphadenopathy 1 (3.03%). Incidental finding were fibroid 3 (9.09%) and adenomyosis 1 (3.03%) case.

CONCLUSION

MRI appears to be useful diagnostic modality for tuberculous TO masses where differential diagnosis is malignancy but molecular diagnosis remains the gold standard.

The COVID-19 and TB syndemic: the way forward

Together, SARS-CoV-2 and M. tuberculosis have killed approximately 5.7 million people worldwide over the past 2 years. The COVID-19 pandemic, and the non-pharmaceutical interventions to mitigate COVID-19 transmission (including social distancing regulations, partial lockdowns and quarantines), have disrupted healthcare services and led to a reallocation of resources to COVID-19 care. There has also been a tragic loss of healthcare workers who succumbed to the disease. This has had consequences for TB services, and the fear of contracting COVID-19 may also have contributed to reduced access to TB services. Altogether, this is projected to have resulted in a 5-year setback in terms of mortality from TB and a 9-year setback in terms of TB detection. In addition, past and present TB disease has been reported to increase both COVID-19 fatality and incidence. Similarly, COVID-19 may adversely affect TB outcomes. From a more positive perspective, the pandemic has also created opportunities to improve TB care. In this review, we highlight similarities and differences between these two infectious diseases, describe gaps in our knowledge and discuss solutions and priorities for future research.

A rare case of complicated pancreatitis due to leptospirosis

The COVID-19 pandemic and the actions taken to combat it have greatly impacted the health infrastructure of all nations. Here we present a rare case of leptospirosis with severe acute pancreatitis, bilateral peripheral gangrene, disseminated intravascular coagulopathy and multiorgan failure. This is a rare presentation of leptospirosis wherein the patient had no history suggestive of acquisition of leptospires. The patient was started on doxycycline but still could not be saved due to the multisystem involvement.

Persistence of SARS-CoV-2 in COVID-19 patients during the second wave of the pandemic in India

INTRODUCTION

India witnessed the catastrophic second wave of COVID-19 during the summer months of 2021. Many patients with non-resolution of symptoms admitted to dedicated COVID-19 treatment centers required prolonged inpatient care which led to the unavailability of beds for other COVID-19 patients. The objective of this study was to determine the duration of SARS-CoV-2 positivity in moderate and severe COVID-19 patients requiring long-term pulmonary care as well as to find out the association between different variables with the persistence of the virus.

METHODOLOGY

A retrospective chart review of clinical and laboratory data of patients with moderate and severe COVID-19 between 1st April 2021 and 15th July 2021 admitted for more than 28 days and requiring long-term pulmonary care was carried out at National Cancer Institute, AIIMS, India. SARS-CoV-2 RNA was detected with real-time reverse transcriptase-polymerase chain reaction-based tests. Data from all consecutively included patients satisfying the selection criteria were presented temporally and analyzed by Fisher's exact test (p < 0.05).

RESULTS

All 51 patients tested positive for SARS-CoV-2 RNA at the 5th week of initial laboratory confirmation of COVID-19. The majority of the patients (38; 74.5%) remained positive for viral RNA till the 6th week and the median duration of viral positivity was 45 days. The clinical presentation of SARI at admission was significantly higher among patients with viral persistence till the 6th week (p < 0.05).

CONCLUSIONS

The median duration of the viral positivity was 45 days and SARI at admission was significantly associated with viral persistence till the 6th week.

2D-DIGE based urinary proteomics and functional enrichment studies to reveal novel Mycobacterium tuberculosis and human protein biomarker candidates for pulmonary tuberculosis

In the absence of a sensitive and specific diagnostic modality capable of detecting all forms of tuberculosis (TB), proteomics may identify specific Mycobacterium tuberculosis (M.tb) proteins in urine, with a potential as biomarkers. To identify candidate biomarkers for TB, proteome profile of urine from pulmonary TB patients was compared with non-disease controls (NDC) and disease controls (DC, Streptococcus pneumonia infected patients) using a combination of two-dimensional difference gel electrophoresis (2D-DIGE) and liquid chromatography tandem mass spectrometry (LCMS/MS). Eleven differentially expressed host proteins and Eighteen high abundant M.tb proteins were identified. Protein-protein interactome (PPI) and functional enrichment analyses like Gene Ontologies, Reactome pathway etc. demonstrated that the human proteins mainly belong to extracellular space and show physiological pathways for immune response and hematological disorders. Whereas, M.tb proteins belong to the cell periphery, plasma membrane and cell wall, and demonstrated catalytic, nucleotide binding and ATPase activities along with other functional processes. The study findings provide valuable inputs about the biomarkers of TB and shed light on the probable disease consequences as an outcome of the bacterial pathogenicity.

Scrub typhus in two COVID-19 patients: a diagnostic dilemma

The authors describe a case series of co-infection with COVID-19 and scrub typhus in two Indian patients. Clinical features like fever, cough, dyspnea and altered sensorium were common in both patients. Case 1 had lymphopenia, elevated IL-6 and history of hypertension, while case 2 had leukocytosis and an increased liver enzymes. Both patients had hypoalbuminemia and required admission to the intensive care unit; one of them succumbed to acute respiratory distress syndrome further complicated by multiple organ dysfunction syndrome. Seasonal tropical infections in COVID-19 patients in endemic settings may lead to significant morbidity and mortality. Therefore, high clinical suspicion and an early diagnosis for co-infections among COVID-19 patients are essential for better patient management.

Spectrum of mycobacterial pathogens responsible for head and neck tuberculosis-like presentation

Tuberculosis (TB) of the head and neck can be contained in the lymph nodes, larynx, oropharynx, salivary glands, nose and paranasal sinuses, ear, skin and skull. Head and neck TB presentations are varied in nature and thus difficult to diagnose. The clinical features, radiological findings, microbiological diagnostic modalities, surgical and medical management and outcomes of nine cases of head and neck TB are discussed in detail here, together with a thorough review of the literature. Patients presented with atypical symptoms such as discharging sinus, ear lobule swelling, otitis media, vision loss and facial weakness, long refractory otorrhoea and granulation tissue in the ear canal. We diagnosed tubercular skull base osteomyelitis (one case) and laryngeal tuberculosis (two cases), mastoid tuberculosis (one case) and non-tubercular mycobacterial infection involving the temporal bone (two cases), sino-nasal region (one case), maxilla (one cases) and ear lobule (one case) over a period of 8 months. All patients were managed successfully with a combination of surgery and a well-planned treatment regimen for non-tuberculous mycobacteria (NTM) or anti-tubercular drugs for TB. All had successful outcomes except one patient with tubercular skull base osteomyelitis who expired before the initiation of anti-tubercular therapy (ATT). High clinical suspicion followed by thorough diagnostic work-up for both TB and NTM would enable early diagnosis and complete treatment.

Hysteroscopic observations in 348 consecutive cases of female genital tuberculosis: A prospective study

STUDY OBJECTIVE

To evaluate the hysteroscopic findings in female genital tuberculosis.

DESIGN

It was a prospective study of hysteroscopic findings performed on 348 cases of female genital tuberculosis (FGTB).

SETTING

It was a prospective cross-sectional study in a tertiary referral centre.

PATIENTS

A total of 348 patients with infertility with FGTB on various tests.

INTERVENTION

A total of 348 patients of infertility found to have FGTB on various investigations were enrolled in the study. A detailed history was taken. Clinical examination, endometrial sampling and diagnostic laparoscopy were performed was also performed in selected cases. All patients underwent hysteroscopy as part of evaluation for infertility and tuberculosis (TB) findings.

MEASUREMENTS AND MAIN RESULTS

The mean age, parity, body mass index and duration of infertility was 28.2 years, 0.31,23.1kg/m² and 3.44 years respectively. Infertility was primary in 81.03% and secondary in 18.96% cases. Diagnosis of FGTB was made by endometrial aspirate findings of positive AFB on microscopy (4.02%), positive culture (4.88%), positive PCR (83.90%), epithelioid granuloma (14.65%), positive AFB on microscopy or culture of peritoneal cytology (1.14%) or epithelioid granuloma on peritoneal biopsy (1.72%), definitive findings of TB on laparoscopy (41.95%) or probable findings of TB on laparoscopy (58.05%). Various hysteroscopic findings observed were normal findings (28.16%), pale endometrial cavity (54.31%), features of active TB (7.47%), features of chronic TB (19.54%), features of TB sequelae like obstructed ostia (both ostia in 13.79%, one ostia 14.94%, periostial fibrosis; (bilateral 4.59%, unilateral 5.17%), endometrial glands atrophy (12.35%), small shrunken cavity (6.32%), distorted cavity (5.17%), various grades of intrauterine adhesions (29.88%). Hysteroscopy in FGTB was associated with increased difficulties and complications like failed procedures, difficult visualisation, false passage and uterine perforation.

CONCLUSION

Hysteroscopy is useful modality to detect endometrial TB but is associated with increased difficulty and complications.

Randomized trial of Metformin with Anti-tuberculosis drugs For Early Sputum Conversion in Adults with Pulmonary Tuberculosis

Background

Metformin, by reducing intracellular Mycobacterium tuberculosis growth, can be considered an adjunctive therapy to anti-tuberculosis treatment (ATT). We determined whether metformin with standard ATT reduces time to sputum culture conversion and tissue inflammation in adults with pulmonary tuberculosis (PTB).

Methods

In a randomized, 8-week, clinical trial, newly diagnosed, culture-positive PTB patients were randomized to standard ATT (HREZ = control arm) or standard ATT plus daily 1000 mg metformin (MET-HREZ = Metformin with Rifampicin [METRIF] arm) for 8 weeks during 2018–2020 at 5 sites in India. The primary end point was time to sputum culture conversion by liquid culture during 8 weeks of ATT. Plasma inflammatory markers were estimated in a subset. A Cox proportional hazard model was used to estimate time and predictors of culture conversion.

Results

Of the 322 patients randomized, 239 (74%) were male, and 212 (66%) had bilateral disease on chest radiograph with 54 (18%) showing cavitation. The median time to sputum culture conversion by liquid culture was 42 days in the METRIF arm and 41 days in the control arm (hazard ratio, 0.8; 95% confidence interval [CI], .624–1.019). After 8 weeks of ATT, cavitary lesions on X-ray (7, 5.3% vs 18, 12.9%; relative risk, 0.42; 95% CI, .18–.96; P = .041) and inflammatory markers were significantly lower in the METRIF arm. Higher body mass index and lower sputum smear grading were associated with faster sputum culture conversion.

Conclusions

The addition of metformin to standard ATT did not hasten sputum culture conversion but diminished excess inflammation, thus reducing lung tissue damage as seen by faster clearance on X-ray and reduced inflammatory markers.

Clinical Trials Registration

Clinical Trial Registry of India (CTRI/2018/01/011176)

Immunohistochemical evaluation of infiltrating immune cells in endometrial biopsy of female genital tuberculosis

BACKGROUND

Female Genital Tuberculosis (FGTB) causes infertility in a large number of females in developing countries. Presence of granuloma on histopathological examination of endometrial samples is diagnostic of FGTB. But immunohistochemical evaluation of endometrial aspirates has not been explored before.

AIM

To evaluate the immunohistochemical delineation of immune cells in FGTB.

METHODS

1515 infertile women from 20 to 35 years were enrolled and underwent endometrial aspiration (EA), which was subjected to microbiological and histopathological examination along with PCR. Patients positive for conventional tests like granulomas, acid fast bacilli, mycobacterial culture on LJ medium or liquid (MGIT) culture were started on antitubercular therapy. Conventional test negative but PCR positive patients were posted for laparoscopy. Immunohistochemistry (IHC) for LCA, CD68, CD3, CD4, CD8, CD 20, CD138, IFN gamma and IL10 were evaluated.

RESULT

38/1515 (2.5%) subjects tested positive for conventional methods. PCR-TB was positive in 615/1515 samples (40.59%). On IHC, the number of CD45 (LCA) positive immune cells (p = 0.03) and IFN gamma (p = 0.002) and IL10 expression (p = 0.012) at 1 + level were higher in the PCR positive samples. Laparoscopy done in 418/463 patients and 89/418 (21.3%) showed definitive findings of tuberculosis. CD3, CD4, CD8, CD20, CD68 and CD138 showed no correlation with PCR and laparoscopy.

CONCLUSION

Increased IFN gamma and IL 10 expressing immune cells in PCR positive EA suggests subclinical early changes, and can be useful as a research tool but have no role in diagnosing FGTB.

Variants of concern responsible for SARS-CoV-2 vaccine breakthrough infections from India

Emerging reports of SARS‐CoV‐2 breakthrough infections entail methodical genomic surveillance for determining the efficacy of vaccines. This study elaborates genomic analysis of isolates from breakthrough infections following vaccination with AZD1222/Covishield and BBV152/Covaxin. Variants of concern B.1.617.2 and B.1.1.7 responsible for cases surge in April–May 2021 in Delhi, were the predominant lineages among breakthrough infections.

Atypical bacterial co-infections among patients with COVID-19: A study from India

Emerging evidence shows co‐infection with atypical bacteria in coronavirus disease 2019 (COVID‐19) patients. Respiratory illness caused by atypical bacteria such as Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila may show overlapping manifestations and imaging features with COVID‐19 causing clinical and laboratory diagnostic issues. We conducted a prospective study to identify co‐infections with SARS‐CoV‐2 and atypical bacteria in an Indian tertiary hospital. From June 2020 to January 2021, a total of 194 patients with laboratory‐confirmed COVID‐19 were also tested for atypical bacterial pathogens. For diagnosing M. pneumoniae, a real‐time polymerase chain reaction (PCR) assay and serology (IgM ELISA) were performed. C. pneumoniae diagnosis was made based on IgM serology. L. pneumophila diagnosis was based on PCR or urinary antigen testing. Clinical and epidemiological features of SARS‐CoV‐2 and atypical bacteria‐positive and ‐negative patient groups were compared. Of the 194 patients admitted with COVID‐19, 17 (8.8%) were also diagnosed with M. pneumoniae (n = 10) or C. pneumoniae infection (n = 7). Confusion, headache, and bilateral infiltrate were found more frequently in the SARS CoV‐2 and atypical bacteria co‐infection group. Patients in the M. pneumoniae or C. pneumoniae co‐infection group were more likely to develop ARDS, required ventilatory support, had a longer hospital length of stay, and higher fatality rate compared to patients with only SARS‐CoV‐2. Our report highlights co‐infection with bacteria causing atypical pneumonia should be considered in patients with SARS‐CoV‐2 depending on the clinical context. Timely identification of co‐existing pathogens can provide pathogen‐targeted treatment and prevent fatal outcomes of patients infected with SARS‐CoV‐2 during the current pandemic.

Coinfections with Other Respiratory Pathogens among Patients with COVID-19

Emerging evidence indicates that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected individuals are at an increased risk for coinfections; therefore, physicians need to be cognizant about excluding other treatable respiratory pathogens. Here, we report coinfection with SARS-CoV-2 and other respiratory pathogens in patients admitted to the coronavirus disease (COVID) care facilities of an Indian tertiary care hospital. From June 2020 through January 2021, we tested 191 patients with SARS-CoV-2 for 33 other respiratory pathogens using an fast track diagnostics respiratory pathogen 33 (FTD-33) assay. Additionally, information regarding other relevant respiratory pathogens was collected by reviewing their laboratory data. Overall, 13 pathogens were identified among patients infected with SARS-CoV-2, and 46.6% (89/191) of patients had coinfection with one or more additional pathogens. Bacterial coinfections (41.4% [79/191]) were frequent, with Staphylococcus aureus being the most common, followed by Klebsiella pneumoniae. Coinfections with SARS-CoV-2 and Pneumocystis jirovecii or Legionella pneumophila were also identified. The viral coinfection rate was 7.3%, with human adenovirus and human rhinovirus being the most common. Five patients in our cohort had positive cultures for Acinetobacter baumannii and K. pneumoniae, and two patients had active Mycobacterium tuberculosis infection. In total, 47.1% (90/191) of patients with coinfections were identified. The higher proportion of patients with coinfections in our cohort supports the systemic use of antibiotics in patients with severe SARS-CoV-2 pneumonia with rapid de-escalation based on respiratory PCR/culture results. The timely and simultaneous identification of coinfections can contribute to improved health of COVID-19 patients and enhanced antibiotic stewardship during the pandemic. IMPORTANCE Coinfections in COVID-19 patients may worsen disease outcomes and need further investigation. We found that a higher proportion of patients with COVID-19 were coinfected with one or more additional pathogens. A better understanding of the prevalence of coinfection with other respiratory pathogens in COVID-19 patients and the profile of pathogens can contribute to effective patient management and antibiotic stewardship during the current pandemic.

Multicentric validation of indigenous molecular test Truenat™ MTB for detection of Mycobacterium tuberculosis in sputum samples from presumptive pulmonary tuberculosis patients in comparison with reference standards

Background & objectives:

Early case detection is essential to interrupt transmission and to prevent further spread of tuberculosis (TB) in high endemic settings. Nucleic acid amplification tests (NAATs) with visual read-outs are ideal as point-of-care tests. Truenat™ MTB is an indigenous chip-based NAAT for detection of Mycobacterium tuberculosis, which involves extraction of DNA and real-time polymerase chain reaction (PCR) using portable, automated, battery-operated instruments. The current multicentric study was aimed to evaluate Truenat for detection of MTB in sputum samples obtained from patients with presumptive pulmonary TB with reference to culture as gold standard and Xpert as a comparator.

Methods:

The study was conducted at four sites, namely ICMR-National Institute for Research in Tuberculosis, Chennai; All India Institute of Medical Sciences, New Delhi; ICMR-National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Agra; and National Institute of TB and Respiratory Diseases, New Delhi. Patients suspected to have TB were screened for eligibility. Two sputum samples were collected from each patient. Tests included smear, Xpert and Truenat directly from the sputum sample and culture by Lowenstein-Jensen (L-J) medium and MGIT960 from decontaminated pellets. Sample used for Truenat assay was coded. Resolution of Truenat false positives was done using an in-house PCR with TRC₄ primers.

Results:

The study enrolled 2419 presumptive TB patients after screening 2465 patients, and 3541 sputum samples were collected from the enrolled patients. Results of 2623 samples were available for analysis. Truenat showed a positivity rate of 48.5 per cent as compared to 37.0 per cent by Xpert. The sensitivities of Truenat and Xpert were was 88.3 and 79.7 per cent, respectively in comparison with culture.

Interpretation & conclusions:

Truenat MTB identified more positives among culture-confirmed samples than Xpert and had higher sensitivity. In addition, other advantageous operational features of Truenat MTB were identified which would be useful in field settings.

Validation of an indigenous assay for rapid molecular detection of rifampicin resistance in presumptive multidrug-resistant pulmonary tuberculosis patients

Background & objectives:

There is a need for an affordable, easy, high-sensitivity test usable at the peripheral health facility for diagnosis of drug-resistant (DR) tuberculosis (TB) to interrupt disease transmission. Nucleic acid amplification tests (NAATs) for early detection of DR-TB are ideal to bring testing near to the patient. Truenat™ MTB (Mycobacterium tuberculosis) and Truenat™ MTB-RIF (rifampicin) is an indigenous chip-based real-time polymerase chain reaction (PCR) based test for detection of multidrug-resistant (MDR) TB. The test involves extraction of DNA using automated, battery operated Trueprep instrument and real-time PCR performed on the Truelab analyzer. We report here multicentric validation of Truenat MTB-RIF for detection of DR-TB in suspected DR-TB patients.

Methods:

Consecutive patients aged 18-65 yr, with symptoms suggestive of TB and with a history of previous treatment, reporting to the National TB Elimination Programme (NTEP) clinics under four national institutes, namely AIIMS (All India Institute of Medical Sciences, New Delhi), NITRD (National Institute of Tuberculosis and Respiratory Diseases, New Delhi), NIRT (National Institute for Research in Tuberculosis, Chennai) and ICMR-National JALMA Institute for Leprosy and other Mycobacterial Diseases, Agra, were included in the study. Two sputum samples (one spot and one morning) were collected from each patient, after obtaining informed written consent. The samples were subjected to smear, GeneXpert and MGIT 960 culture (and drug susceptibility testing to RIF) (surrogate for MDR-TB) to serve as reference tests. The samples were coded to ensure blinding and subjected to Truenat MTB-RIF. Truenat MTB-RIF Version 1.5 was used for testing 1084 samples for RIF resistance, while Version 2.0 was used to test another 1201 samples.

Results:

Truenat MTB-RIF Version 1.5 in comparison with comprehensive laboratory reference standards yielded sensitivity and specificity of 76.2 and 94.7 per cent, respectively for the detection of RIF resistance in 1084 samples, collected across four sites. Based on the analysis of discordant samples, Version 2.0 of Truenat was developed by the manufacturer and this was further tested on additional 1201 samples, yielding a sensitivity of 87.5 per cent and specificity of 99.5 per cent.

Interpretation & conclusions:

Multicentric trial of Truenat™ MTB-RIF demonstrated a great potential of this point of care NAAT for detection of MDR-TB. The test would be useful in limited resource settings and inaccessible areas without need for any additional infrastructure.

Childhood Intra-Thoracic Tuberculosis Clinical Presentation Determines Yield of Laboratory Diagnostic Assays

Diagnosis of intra-thoracic tuberculosis (ITTB) in children is difficult due to the paucibacillary nature of the disease, the challenge in collecting appropriate specimens, and the low sensitivity of smear microscopy and culture. Culture and Xpert MTB/RIF provide higher diagnostic yield in presumptive TB in adults than in children. Current study was designed to understand poor yield of diagnostic assays in children. Children with presumptive ITTB were subjected to gastric aspirates and induced sputum twice. Samples were tested by Ziehl-Neelsen stain, Xpert MTB/RIF-assay, and MGIT-960 culture. Subjects were grouped as Confirmed, Unconfirmed, and Unlikely TB, and classified as progressive primary disease (PPD, lung parenchymal lesion), and primary pulmonary complex (PPC, hilar lymphadenopathy) on chest X-ray. Of children with culture-positive TB 51/394 (12.9%), culture-negative TB 305 (77.4%), and unlikely TB 38 (9.6%), 9 (2.3%) were smear positive, while 95 (24.1%) were Xpert-MTB/RIF positive. Xpert-MTB/RIF detected 40/51 culture confirmed cases (sensitivity 78.4% and NPV 96.3%). Culture was positive in more children presenting as PPD (p < 0.04). In culture-negative TB group, Xpert positivity was seen in 31% of those with PPD and 11.9% in those with PPC (p < 0.001). Conclusion: Xpert-MTB/RIF improved diagnosis by 2-fold and increased detection of MDR-TB. Both liquid culture and Xpert-MTB/RIF gave higher yield in children with lung parenchymal lesions. Children with hilar lymphadenopathy without active lung parenchymal lesions had poor diagnostic yield even with sensitive nucleic acid amplification tests, due to paucibacillary/localized disease, suggesting possible utility of invasively collected samples in early diagnosis and treatment.

Evaluation of Gene Xpert as compared to conventional methods in diagnosis of Female Genital Tuberculosis

To evaluate Gene Xpert for diagnosis of Female Genital Tuberculosis (FGTB) as compared to conventional methods.

STUDY DESIGN

It was a prospective study conducted over 167 cases of infertile female genital tuberculosis (FGTB) diagnosed on composite reference standard (CRS) (smear for AFB, histopathological evidence of epithelioid granuloma or definite or possible findings of tuberculosis on laparoscopy). All women underwent endometrial biopsy for AFB microscopy, culture, gene Xpert, PCR and histopathology) and laparoscopy and hysteroscopy for diagnosis and prognostication of disease. The results of Gene Xpert were compared with conventional methods in detection of FGTB. All patients were treated with 6 months course of rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol (E) (RHZE for 2 months, RHE for 4 months) using directly observed treatment short course strategy.

RESULTS

Mean age, parity, body mass index and history of contact was 28.3 years, 0.28, 22.9 Kg/m² and 38.92% respectively. Primary infertility was seen in 87.42% cases with mean duration of 2.42 years. Menstrual dysfunctions, abdominal or pelvic pain and lump were seen in 38.92%, 14.37% and 10.77% cases. Abnormal vaginal discharge and adnexal mass were seen in 28.14% and 13.17 % cases. On diagnostic laparoscopy, definite findings of tuberculosis (beaded tubes, tuebrcles and caseous nodules) were seen in 96 (57.48%) women while probable findings of tuberculosis (pelvic or abdominal adhesions, hydrosaplinx, tubo-ovarian mass, pyosalpinx) were seen in 81 (48.50%) women. On laboratory investigations, positive AFB on microscopy or culture was seen in 2.99% casess, PCR was positive in 47.90% gene Xpert was positive in 18.56% cases while epitheloid granuloma was seen on histopathology in 16 (9.58%) cases. Gene Xpert had sensitivity of 35.63%, specificity of 100%, positive predictive value of 100% and negative predictive value of 58.82% and diagnostic accuracy of 66.47% in the present study.

CONCLUSION

Gene Xpert is a very useful test to rule in tuberculosis whereas when it is negative it is not a good test to rule out tuberculosis.

Acceptability and Adherence to Peanut-Based Energy-Dense Nutritional Supplement Among Adult Malnourished Pulmonary Tuberculosis Patients in Ballabgarh Block of Haryana, India

BACKGROUND

Undernutrition is a leading risk factor for tuberculosis and is associated with adverse treatment outcomes. Energy-dense nutritional supplement (EDNS) may be helpful in managing undernutrition in tuberculosis patients.

METHODS

A longitudinal study was conducted among 102 newly diagnosed pulmonary tuberculosis patients in the Ballabgarh tuberculosis unit in Haryana, India, between September 2018 and February 2019. Participants were provided daily supplementation with 2 sachets of peanut-based EDNS providing 1000 kcal along with the tuberculosis chemotherapy for 2 months. Acceptability was assessed after one month of supplementation. Reported side effects were assessed every 15 days for 2 months and adherence, in terms of proportion of supplement consumed, was assessed on weekly basis for 2 months. Weight was measured at baseline and after 1 month and 2 months.

RESULTS

Mean age of participants was 33 years (standard deviation: 13.8) and 75.5% of the participants were male. Almost 100% of the participants found the taste, smell, consistency, and color of the EDNS acceptable. Three participants rejected it after one month of consuming EDNS and another 7 rejected after 2 months of consuming EDNS. After consuming EDNS for 2 months, 13.9% of the participants complained of nausea, 11.9% complained of vomiting, 10.9% complained of diarrhea, and 9.9% complained of pain in the abdomen and abdominal fullness or bloating anytime during the period of supplementation. The adherence to EDNS among the participants was reported as 92.6%.

CONCLUSION

A peanut-based EDNS was highly acceptable and safe, and the adherence to it was high among patients with pulmonary tuberculosis.

Evaluation of 'TBDetect' sputum microscopy kit for improved detection of Mycobacterium tuberculosis: a multi-centric validation study

OBJECTIVES

The present study aimed to evaluate the performance of the 'TBDetect' kit-based bio-safe fluorescent microscopy filter (BioFM-Filter) microscopy in comparison with direct smear microscopy and culture for the detection of pulmonary tuberculosis (TB) in a multi-centric setting in India.

METHODS

The TBDetect kit enables sputum concentration through filtration using the BioFM-Filter for improved and bio-safe smear microscopy. We evaluated the performance of the TBDetect kit in a six-site multi-centric validation study on sputum collected from 2086 presumptive TB patients.

RESULTS

The combined positivity of TBDetect microscopy performed on these sputum samples was 20% (n = 417/2086) vs 16.1% of light-emitting diode fluorescence microscopy (LED-FM, n = 337/2086) and 16% of Ziehl Neelsen (ZN) smear microscopy (n = 333/2086). The increment in positivity of TBDetect over both LED-FM and ZN smears was significant (p < 0.001). The overall sensitivity of TBDetect for six sites was ~55% (202/367, 95% confidence interval (CI): 50, 60%) vs 52% (191/367, 95% CI: 47, 57%) for LED-FM (p 0.14) and 50.9% (187/367, 95% CI: 46, 56%) for ZN smear (p < 0.05), using Mycobacterium Growth Indicator Tube culture (MGIT, n = 1949, culture positive, n = 367) as the reference standard. A bio-safety evaluation at six sites confirmed efficient sputum disinfection by TBDetect; 99.95% samples (1873/1874) were sterile after 42 days of incubation. Scientists and technicians at the study sites indicated the ease of use and convenience of TBDetect microscopy during feedback.

CONCLUSIONS

TBDetect added value to the smear microscopy test due to its improved performance, convenience and user safety. These findings indicate that equipment-free TBDetect technology has the potential to improve TB diagnosis in basic laboratory settings by leveraging on the existing nationwide network of designated microscopy centres and primary healthcare centres.

Role of Laparoscopy in the Diagnosis of Genital TB in Infertile Females in the Era of Molecular Tests

STUDY OBJECTIVE

To assess diagnostic value of polymerase chain reaction (PCR) in endometrial aspirates (EAs) in comparison with conventional tests for diagnosis of female genital tuberculosis (TB) and to find agreement between EA PCR done for endometrial TB and laparoscopic findings of pelvic TB in women with unexplained infertility.

DESIGN

Prospective observational cohort study.

SETTING

Tertiary care hospital.

PATIENTS

A total of 732 infertile females screened and 385 enrolled to undergo procedure to obtain EAs.

INTERVENTIONS

EAs were tested by conventional tests (histopathology, acid-fast bacilli, Lowenstein-Jensen staining, liquid culture) and PCR for Mycobacterium tuberculosis. Patients with positive conventional tests were started on antitubercular treatment (ATT). Patients with negative conventional tests underwent laparohysteroscopy irrespective of PCR results to assess changes of tubercular infection in the pelvis. Peritoneal washings were also sent for liquid culture and PCR for TB, and suspicious lesions were biopsied at laparohysteroscopy. Findings at laparoscopy upgraded the diagnosis in these women. EAPCR results were analyzed to find agreement with the findings at laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Conventional tests were positive in 8 of 385 (2%) patients. PCR was positive in 58.1% (n = 224) of endometrial samples, with sensitivity of 62.5% (95% confidence interval [CI], 24.49-91.48), specificity of 41.91% (95% CI, 36.88-47.07), positive predictive value of 2.23% (95% CI, 1.31-3.78), negative predictive value of 98.14% (95% CI, 95.53-99.24), and a diagnostic accuracy of 42.34% (95% CI, 37.35-47.45) with conventional tests. A total of 265 patients underwent laparoscopy, of whom 165 were PCR positive and 100 were PCR negative. Laparoscopic findings suggestive of TB were found in 39.3% of patients who were PCR positive and 9% of patients who were PCR negative. Kappa agreement was 0.25, suggesting fair agreement between PCR and laparoscopy.

CONCLUSION

PCR as a stand-alone diagnostic test for endometrial TB is not justified to confirm diagnosis and initiate ATT. The addition of laparohysteroscopy improves diagnostic yield for genital TB. Referring patients with a suspicion of female genital TB to tertiary care for 1-time laparoscopy is better than initiating ATT solely on the basis of PCR results.

Thermophilic ligno-cellulolytic fungi: The future of efficient and rapid bio-waste management

To accelerate the process of decomposition using consortia of thermophilic ligno-cellulolytic fungi, different crop residues viz. sorghum (SG), soybean (SS), maize (MS), sugarcane (SC), cotton (CS) and pigeon pea (PS) with a varied C:N ratio and sawdust (SD) having high lignin content were collected and used for decomposition process. Compost quality assessed by evaluating different maturity and stability indices at five succeeding stages [first mesophilic (M1), thermophilic (T), second mesophilic (M2), cooling (C) and humification (H)]. A significant reduction was observed in the C:N ratio, biodegradability index, nitrification index, ratio of water-soluble carbon to organic nitrogen (WSC/Org.N) with an increase in concomitant over time while Ash (%), organic matter loss (%), CEC/TOC ratio, cellulose biodegradation ratio (BR) and lignin/cellulose ratio were significantly increased with time. By correlation study, biodegradability index (BI) and fluorescein diacetate (FDA) hydrolysis emerged as the most suitable compost maturity and stability parameters, respectively. Principal component analysis (PCA) results confirmed that BI, BR, WSC/Org. N and FDA can be regarded as key indicators for assessing compost quality. Our findings conclude that fungal consortia of Tricoderma viride, Rhizomucor pusillus, Aspergillus awamori and Aspergillus flavus can accelerate decomposition time from 8 to 12 months (which is normal farming practice) to 120 days.

Cervical tuberculous lymphadenitis: Clinical profile and diagnostic modalities

Background

Tuberculosis is a major global health problem. Tuberculous lymphadenopathy is a most common form of extrapulmonary tuberculosis (EPTB), constitutes 35% of all cases of EPTB. Due to the paucibacillary nature of specimens, smear microscopy and culture offer low sensitivity.

Methods

The aim of the present study was to find the clinicodemographic profiles and comparing the performance of Xpert MTB/RIF, conventional polymerase chain reaction (PCR), mycobacteria growth indicator tube (MGIT) 960, histopathological examination, and clinical follow-up of patients in diagnosing of smear-negative tuberculous lymphadenopathy.

Results

A total of 140 clinically suspected cervical tuberculous lymphadenitis cases were enrolled in this study. MGIT-960 culture, conventional PCR, and Xpert MTB/RIF were performed. Most of the patients presented with unilateral (87.14%), single (81.42%), matted (87.85%) lymph nodes, 3 cm-6 cm (52.14%), commonly in the right side (68.02%), and associated lung lesion was found in 12.86% of cases. The detection rates of Mycobacterium tuberculosis complex (MTBC) by Xpert MTB/RIF, conventional PCR, and MGIT were 25.71%, 20.71%, and 17.85%, respectively. Both the tests: Xpert MTB/RIF and PCR, PCR and MGIT, Xpert MTB/RIF and MGIT were positive in 15.71%, 15.71%, and 11.42% of cases, respectively. Most of the patients (74.1%) were cured with 6 months of antitubercular drugs.

Conclusion

Clinicians often face the diagnostic dilemmas presented in the study. Individual modalities of the diagnosis are available, but all have drawbacks with varied sensitivity and specificity. Combining the available clinical, radiological, and microbiological modality to reach early diagnosis can go a long way to avoid misdiagnosis and unnecessary delay in treatment, especially in cases, without the pulmonary involvement and fulfilling the aim of National Tuberculosis Control Programme for EPTB cases.

Mycobacterium abscessus Periprosthetic joint infection following bilateral Total Knee arthroplasty

Periprosthetic joint infection (PJI) can be protracted, incapacitating, needing multiple interventions and could even lead to mortality. Early post-operative PJI has been ascribed to peri-operative introduction of highly virulent bacteria, while delayed post-operative to low-virulence bacteria. Non-tuberculous mycobacteria (NTM) do not figure in the usual list of etiological agents. We report a case of difficult diagnosis of bilateral PJI caused by Mycobacterium abscessus, following bilateral total knee arthroplasty in an elderly male, but treated successfully despite prolonged infection. M. abscessus complex comprises a group of rapidly growing, multidrug-resistant NTM, capable of forming biofilms on prostheses, responsible for wide spectrum of hospital acquired infections. M. abscessus as a cause of PJI is not reported widely. There are a few cases described in literature worldwide. There are no policy guidelines available for treating such cases. High clinical suspicion, with a concerted effort to grow and identify the causal pathogen is important. Standard anti-tubercular therapy is not recommended for treatment due to inherent resistance. Complete excision of infected tissues and removal of prosthesis along with prolonged combination antimicrobial regimen is the treatment of choice.

Compromised longevity due to Mycobacterium abscessus pulmonary disease in lungs scarred by tuberculosis

Structural lung diseases or scarring related to prior infections such as tuberculosis (TB) are risk factors for the development of invasive nontuberculous mycobacterial (NTM) pulmonary infections, such as Mycobacterium abscessus. M. abscessus is intrinsically resistant to many antibiotics and in vitro susceptibility correlates poorly with clinical response, especially in pulmonary disease. Treatment is often difficult due to the lack of effective antibiotic regimens. We present a case of a 56-year-old male previously treated for TB, with presumed exacerbation, who was diagnosed after much delay with pulmonary M. abscessus disease and subsequently failed initial treatment with an empirical antibiotic regimen. When placed on a synergistic combination regimen that included amikacin, linezolid, clarithromycin, ethambutol and faropenem, the patient showed a favourable response and was culture-negative for over 12 months when the treatment was stopped as per American Thoracic Society (ATS) recommendations. Unfortunately, he developed recurrent symptoms and died 9 months after stopping treatment, following an acute exacerbation of fever and respiratory failure.

Granulomatous hepatitis by Nocardia species: An unusual case

A case of granulomatous hepatitis due to Nocardia is reported here. The case patient was a 63-year-old immunocompetent man who presented with persistent fever, weight loss, and malaise. Radiology suggested an enlarged liver with dense diffuse to multiple tiny micronodular areas of parenchymal involvement, possibly granulomatous. Liver biopsy showed necrotizing granulomas and anti-tuberculosis therapy was initiated, but the patient showed no improvement. A repeat liver biopsy showed similar histopathology; however PCR for Mycobacterium tuberculosis was negative, while MGIT 960 culture grew filamentous Gram-positive bacilli, acid-fast by 1% H₂SO₄, identified biochemically as Nocardia spp. 16S rRNA sequencing confirmed Nocardia spp. A diagnosis of granulomatous hepatitis due to Nocardia spp. was made. Treatment based on drug sensitivity testing was initiated, resulting in a resolution of symptoms. The patient's history revealed that stray dogs adopted by his family had skin lesions, likely canine distemper (two newborn puppies had died recently). Nocardia is known to co-infect animals with distemper. This could have been the possible source of a zoonotic infection to the case patient. Nocardia spp. are seldom reported from sites other than the lungs, skin, or brain; the current case highlights the involvement of the liver. Due to the granulomatous tissue response, it could represent a differential diagnosis of tuberculosis in such cases.

Diagnostic Yield of Xpert MTB/RIF in Bronchoalveolar Lavage in Children with Probable Pulmonary Tuberculosis

OBJECTIVE

To evaluate utility of Xpert MTB/RIF in bronchoalveolar lavage fluid in children with probable pulmonary tuberculosis.

METHODS

Children with probable pulmonary tuberculosis with negative smear and Xpert on induced sputum/gastric aspirate were subjected to bronchoalveolar lavage (BAL) for Xpert assay and mycobacterial liquid culture. Data of children <14 y undergoing bronchoscopy for suspected MDR-TB (n=12) were also analyzed. The sensitivity of Xpert in BAL fluid for diagnosis of probable and confirmed pulmonary tuberculosis was calculated with clinico-radiological diagnosis and culture as gold standards, respectively.

RESULTS

Of 41 enrolled children, 24 (58.5%) had Xpert positive in BAL fluid and 11 (26.8%) had culture confirmed tuberculosis (BAL fluid;10; sputum,1). The sensitivity of Xpert in BAL fluid among probable and culture confirmed tuberculosis cases was 58.5% (24/41) and 81.8% (9/11), respectively.

CONCLUSION

Xpert in bronchoalveolar lavage fluid has good sensitivity in both probable and confirmed pulmonary tuberculosis in children.

Circulating Antimicrobial Peptide LL-37 Status in Type 1 Diabetes Mellitus and its Relation with Glycemic Control

Antimicrobial-peptides are important molecules of constitutive innate immunity. Though patients with diabetes mellitus are generally prone to infections, there is limited information on their antimicrobialpeptide status. We assessed the circulating LL-37 antimicrobial peptide (also referred as cathelicidin) levels in patients with type 1 diabetes mellitus and its relation with their glycemic status. The LL-37 mRNAexpression was assessed in the peripheral blood mononuclear cells (PBMC) by quantitative RTPCR using ß-actin and cytochrome-C1 as the reference genes in 154 subjects (Type 1 diabetes, n=111 and healthy subjects, n=43). Serum LL-37 was quantified using sandwich-ELISA. Average HbA1c over last 2 years and current HbA1c were used to determine long-term and short-term glycemic status. LL-37 mRNAexpression and serum LL-37 levels were correlated with the glycemic status. The LL-37 mRNA copies were comparable between type 1 diabetes and healthy subjects [median (IQR) = 6.7 (1.8–15.28) vs. 7.2 (2.23–21.86), respectively, P = 0.42]. There was no significant difference in serum LL-37 levels between the two groups [median (IQR) = 3.9 (2.88–7.52) vs. 5.0 (3.19–9.05) ng/ml, respectively, P = 0.52]. The LL-37 mRNA and its protein concentration showed no significant correlation with the average or current HbA1c values. The constitutive circulating antimicrobial peptide LL-37 status is not significantly altered in patients with type 1 diabetes mellitus and also not affected by their glycemic status.

Role of anti-tubercular treatment for positive endometrial aspirate DNA-PCR reproductive outcome in infertile patients in Indian setting - A randomized trial

AIMS

The aim of the study was to determine the effect of anti-tubercular therapy (ATT) versus no ATT on reproductive outcome in patients with positive endometrial aspirate DNA-PCR for tuberculosis.

SETTINGS AND DESIGN

Department of Obstetrics and Gynecology in collaboration with the Department of Microbiology at the All India Institute of Medical Sciences, New Delhi, India.

METHODS AND MATERIALS

This prospective randomized study was conducted on 100 women in the reproductive age group with primary or secondary infertility, attending the Gynecology OPD at AIIMS. Women with positive endometrial DNA-PCR, patent tubes on laparoscopy, and all other tests being negative for genital TB were randomized into two groups. In Group 1, patients received ATT for 6 months while in Group 2, patients were not given ATT. In patients who did not conceive a repeat endometrial sampling for DNA-PCR was performed at 6 months and 12 months post-laparoscopy.

STATISTICAL ANALYSIS

It was carried out using Stata 11.0 (College Station, TX, USA).

RESULTS

In Group 1 (ATT), 25 women achieved pregnancy with a pregnancy rate of 50% while in Group 2 (no ATT), 21 women achieved pregnancy with a pregnancy rate of 42% and the difference (95% CI) was 8.0% (-11.5%, 27.5%) which was not statistically significant (p=0.422). Difference (95% CI) in the rate of repeat EA DNA-PCR being positive between the two groups at 6 months was 3.1% (-2.9%, 9.1%), p=0.299, while at the end of 12 months, repeat DNA-PCR remained positive in 23 patients in Group 1 and in 26 patients in Group 2. Difference (95% CI) in the rate of repeat EA DNA-PCR being positive between the two groups at 12 months was 2.3% (-13.0%, 17.7%), p=0.767.

CONCLUSION

The present study does not validate ATT for positive DNA-PCR; however, it does provide an evidence to stop over-treating patients on the basis of positive EA DNA-PCR even after they have received a 6 months course of ATT. Repeating PCR at 6 months and at 12 months has no role and ATT should not be repeatedly given to the patient on the basis of repeat DNA-PCR alone.

CLINICAL TRIAL REGISTRATION NUMBER

CTRI/2015/10/006235, www.ctri.nic.in.

Six months versus nine months anti-tuberculous therapy for female genital tuberculosis: a randomized controlled trial

OBJECTIVE

To compare six months versus nine months anti-tuberculous therapy in patients of female genital tuberculosis.

STUDY DESIGN

It was a randomized controlled trial in a tertiary referral center teaching institute on 175 women presenting with infertility and found to have female genital tuberculosis on clinical examination and investigations. Group I women (86 women) were given 9 months of intermitted anti-tuberculous therapy under directly observed treatment short course (DOTS) strategy while Group II (89 women) were given 6 months of anti-tuberculous therapy under DOTS. Patients were evaluated for primary end points (complete cure, partial response, no response) and secondary end points (recurrence rate, pregnancy rate) during treatment. All patients were followed up further for one year after completion of therapy to assess recurrence of disease and further pregnancies.

RESULTS

Baseline characteristics were similar between two randomized groups. There was no difference in the complete clinical response rate (95.3% vs 97.7%, p=0.441) between 9-months and 6-months groups. Four patients in 9-months group and two patients in 6-months group had recurrence of disease and required category II anti tuberculous therapy (p=0.441). Pregnancy rate during treatment and up to one year follow up was also similar in the two groups (23.2% vs 21.3%, p=0.762). Side effects occurred in 27(31.4%) and 29(32.6%) in 9-months and 6-months of therapy and were similar (p=0.866).

CONCLUSIONS

There was no difference in complete cure rate, recurrent rate and pregnancy rate for either 6-months or 9-months of intermittent directly observed treatment short course anti-tuberculous therapy in female genital tuberculosis.

CLINICAL TRIAL REGISTRATION

The trial was registered in clinicaltrials.gov with registration no: CTRI/2009/091/001088.