Extrapulmonary tuberculosis presenting as hemorrhagic pleuro-pericardial effusions with pericardial mass

Key Clinical Message

Tuberculosis (TB) pericarditis, while uncommon, should be considered in patients with pericardial masses and effusion. Timely recognition and treatment with anti-TB medications are crucial for a successful outcome.

Abstract

TB pericarditis presenting as a pericardial mass is an unusual and rare manifestation of this disease. We report a 59-year-old South Asian male who presented with a 1-week history of dyspnea and cough. He was found to have a hemorrhagic pericardial mass with a massive pericardial effusion. Pleural fluid analysis was positive for TB. The patient was successfully treated with anti-TB medications. Although rare, tuberculous pericardial involvement should be suspected in patients presenting with symptoms of pericardial masses and effusion.

Burden of Tuberculosis in End Stage Renal Disease Patients Undergoing Maintenance Hemodialysis: A Multicenter Study and Experience from Ethiopian Dialysis Setting

Background

Patients with end stage renal disease (ESRD) are at a higher risk of developing tuberculosis (TB) due to the immunosuppressed state along with concomitant comorbidities and socioeconomic and demographic factors. Data on the prevalence of tuberculosis in ESRD are scarce despite the high burden of the disease in developing nations.

Methods

A multicenter, cross-sectional study was conducted at eight dialysis centers in Addis Ababa on the prevalence of TB among CKD patients on maintenance hemodialysis from August 2022 to October 2022 G.C. The study enrolled 263 participants selected by systematic random sampling. Data were collected by reviewing the patient's electronic medical records. The Collected data were analyzed using SPSS version 26.0.

Results

Our study found a 27% prevalence of TB in patients with ESRD receiving maintenance hemodialysis (MHD). Pulmonary tuberculosis was the most prevalent form, and lymphadenitis was the most common extra-pulmonary tuberculosis (EPTB). Only 5.6% of the study participants had microbiologic evidence of TB. Chemistry and cytological studies from pleural fluid and imaging evidences were commonly used diagnostic modalities. The presence of HIV infection, longer duration of dialysis (>1 year), and contact history with a known TB patient were all significantly associated with higher prevalence of TB among the study participants.

Conclusion

Although there is a strong association between TB and CKD, there are no local data from Ethiopia. Our study identified a higher prevalence of TB among CKD patients on MHD. Thus, maintaining a high index of suspicion and early diagnosis and treatment of TB among ESRD patients on MHD and use of TB preventive therapy (TPT) is important in decreasing morbidity and mortality.

Coeliac lymph node abscess: A case report of a rare manifestation of extrapulmonary tuberculosis

Tuberculosis is a leading cause of death worldwide, especially in developing countries. It can affect any site in the body and have a myriad of presentations making diagnosis challenging. Tuberculous lymphadenitis in the abdomen is rare. We present a case of a 42-year-old man who presented with non-specific abdominal symptoms and was found to have an intraabdominal abscess on computed tomography scan of the abdomen. Endoscopic ultrasound-guided aspiration was performed, and tuberculosis was confirmed. This case highlights the importance of having a high clinical suspicion of tuberculosis even with vague symptoms in tuberculosis endemic countries. This would prevent unnecessary surgery as tuberculosis is responsive to anti-tuberculosis drugs.

Diagnostic accuracy of the IFN-γ release assay using RD1 immunodominant T-cell antigens for diagnosis of extrapulmonary tuberculosis

The diagnosis of extrapulmonary tuberculosis (EPTB) poses a significant challenge, with controversies surrounding the accuracy of IFN-γ release assays (IGRAs). This study aimed to assess the diagnostic accuracy of RD1 immunodominant T-cell antigens, including ESAT-6, CFP-10, PE35, and PPE68 proteins, for immunodiagnosis of EPTB. Twenty-nine patients with EPTB were enrolled, and recombinant PE35, PPE68, ESAT-6, and CFP-10 proteins were evaluated in a 3-day Whole Blood Assay. IFN-γ levels were measured using a Human IFN-γ ELISA kit, and the QuantiFERON-TB Gold Plus (QFT-Plus) test was performed. Predominantly, the patients were of Afghan (62%, n = 18) and Iranian (38%, n = 11) nationalities. Eighteen individuals tested positive for QFT-Plus, accounting for 62% of the cases. The positivity rate for IGRA, using each distinct recombinant protein (ESAT-6, PPE68, PE35, and CFP-10), was 72% (n = 21) for every protein tested. Specifically, among Afghan patients, the positivity rates for QFT-Plus and IGRA using ESAT-6, PPE68, PE35, and CFP-10 were 66.7%, 83.3%, 83.3%, 77.8%, and 88.9%, respectively. In contrast, among Iranian patients, the positivity rates for the same antigens were 54.5%, 54.5%, 54.5%, 63.6%, and 45.5%, respectively. In conclusion, our study highlights the potential of IGRA testing utilizing various proteins as a valuable diagnostic tool for EPTB. Further research is needed to elucidate the underlying factors contributing to these disparities and to optimize diagnostic strategies for EPTB in diverse populations.

Foot and ankle tuberculosis: A case report and review of the literature

Key clinical message

It is important to consider foot and ankle tuberculosis (TB) as a potential cause of cystic lesion around the ankle, especially in patients with a history of TB. Early diagnosis and treatment with a rifampin-based regimen for a duration of 12 months can lead to good functional and clinical outcomes.

Abstract

Skeletal TB is an uncommon accounting for 10% of extra-pulmonary TB may present slowly over an extended period of time, making a diagnosis difficult and time-consuming (Microbiology Spectr. 2017;5:5). For the best possible outcome and to reduce the risk of deformity diagnosis must be early (Foot (Edinb). 2018;37:105). For the treatment of drug-susceptible musculoskeletal illness, a rifampin-based regimen lasting 12 months is advised (Clin Infect Dis. 2016;63:e147; J Bone Joint Surg Br. 1993;75:240; Tubercle. 1986;67:243). A 33-year-old female who are working as nurse with diffuse, persistent and low in intensity ankle pain not aggravated relieved by analgesia and swelling over a period of 2 months, static not related to activity. With past medical history of partially treated pulmonary TB 1 year ago. She reported night sweats and low-grade fever during this period, and she denied any history of trauma. The right ankle was globally swollen and tender anteriorly and on the lateral malleolus. The skin over the ankle showed dark discoloration with cautery marks with no discharging sinuses. The range of motion of the right ankle was decreased. The plain x-ray of the right ankle showed three cystic lesion at the distal tibia, one cyst at the lateral malleolus and another one at the calcaneum. Surgical biopsy and expert gene test confirmed the diagnosis of tuberculous osteomyelitis. The patient was planned for surgical curettage of the lesion. After the confirmation of the diagnosis of TB with the biopsy and gene expert test, with consultation of senior chest physician the patient fitted to anti-tuberculous regimen. The patient had good functional and clinical outcome. This case report highlights the importance of considering skeletal TB as a potential cause of musculoskeletal symptoms, especially in patients with a history of TB. Early diagnosis and treatment with a rifampin-based regimen for a duration of 12 months can lead to good functional and clinical outcomes. Further research on the management and prevention of musculoskeletal TB is warranted to improve patient outcomes. The lesson behind this case is that the diagnosis TB osteomyelitis should be on the top of differential diagnosis of multiple cystic lesions around the foot and ankle especially in area where TB is endemic. Early diagnosis and early start of anti-tuberculous therapy can lead to full cure of the patient and in bad situation can minimize the complications.

Cutaneous and Pulmonary Tuberculosis-Diagnostic and Therapeutic Difficulties in a Patient with Autoimmunity

Cutaneous tuberculosis (CTB) is a very rare disease and accounts for only 1-2% of cases of extrapulmonary tuberculosis (EPTB). Due to the variety of its clinical manifestations, the uncharacteristic appearance of its lesions, resembling other dermatoses in the early stages, and the limited experience of clinicians due to the rarity of CTB, diagnosis is very difficult. Particularly noteworthy is the fact that most cases of EPTB, including skin tuberculosis (TB), can be a manifestation of systemic involvement. In this paper, we present a case of an immunocompromised patient who was diagnosed with CTB almost a year after the first dermatological lesions were located on the lower extremities. At the same time, due to respiratory symptoms, a diagnosis of pulmonary TB (PTB) was made, and radiological and microbiological confirmations were obtained.

Culture filtrate supplementation can be used to improve Mycobacterium tuberculosis culture positivity for spinal tuberculosis diagnosis

Culture remains the gold standard to diagnose spinal tuberculosis (STB) despite the paucibacillary nature of the disease. Current methods can take up to 42 days to yield a result, delaying the ability to rapidly detect drug resistance. Studies have demonstrated the use of supplementation with culture filtrate (CF) from an axenic culture of Mycobacterium tuberculosis (Mtb) as a source of growth factors to improve culture rates. Our objective was to test a modified culture assay, utilizing CF supplemented media (CFSM), to improve culture positivity rates for suspected STB. Twelve patients with suspected STB were assessed by conventional culture (BACTEC™ MGIT 960), GeneXpert™ and standard histopathological examination. Spinal biopsies were taken from areas of diseased vertebral tissue or abscess, predetermined from MRI. Additional biopsies were obtained to assess CFSM for improved detection and faster culture of Mtb. All cases were diagnosed as STB and treated empirically for tuberculosis based on either bacteriological evidence (GeneXpert™, MGIT and/or CFSM positive), or based on clinical presentation. 5 specimens (45.45%) were positive for Mtb DNA as detected by GeneXpert™ and 1 specimen (8.33%) was cultured using MGIT (time to detection; 18 days). CFSM was able to culture 7 specimens (58.3%), with all CFSM positive specimens yielding a culture within 14 days. Two samples were positive only using the CFSM assay pointing to additional yield for diagnostic workup. Modification of standard culture can improve detection of Mtb and reduce time to positivity in individuals with STB where culture material is a requirement.

Clinical Outcomes of Delayed Osteoarticular Tuberculosis: A Review of 30 Cases

Purpose

The lack of knowledge regarding osteoarticular tuberculosis (TB) cases in Indonesia leads to delayed and chronic conditions. This study aims to evaluate clinical outcomes of patients with osteoarticular TB.

Materials and Methods

Thirty osteoarticular cases were retrospectively analyzed, with a focus on non-immunocompromised patients without spine involvement. Chemotherapy length, operative treatment method, and infection recurrence were evaluated.

Results

The majority (60%) of patients were aged between 19 to 49 years. The most common complaint was painful swelling, particularly during physical activity. Weight-bearing joints, such as the hips, knees, and ankles, were the most affected. Laboratory results showed over half of the patients had anemia, 96% had elevated erythrocyte sedimentation rate (ESR), and 76% had elevated C-reactive protein (CRP) levels. Radiological findings varied, with lytic lesions, abscesses, and joint destruction observed. All patients presented with pathognomonic histological tubercle appearances, with caseous necrosis, lymphocytes, and Langhans giant cells present. Twenty-nine cases were treated with anti-TB drugs for 12 months, while one recurrent case received the drugs for 24 months. All patients underwent surgery to gain local infection control.

Conclusion

Osteoarticular TB is a common manifestation of extrapulmonary TB and must not be overlooked. Early detection of osteoarticular TB may prevent limb morbidity. Although anti-TB drugs are the primary treatment for osteoarticular TB, in some cases, surgery is required to establish a diagnosis and gain local infection control.

Clinical Characteristics and Outcomes in Chronic Kidney Disease Patients with Tuberculosis in China: A Retrospective Cohort Study

Background

The diverse manifestations of tuberculosis (TB) in chronic kidney disease (CKD) patients can cause difficulty in diagnosis, delayed treatment, even death. Therefore, this study investigated the clinical characteristics and the risk factors for mortality in CKD patients with TB.

Methods

This retrospective study included 167 patients diagnosed with active TB at two tertiary medical centers in Chongqing within six years. Clinical characteristics and outcomes of anti-TB treatment in patients with and without CKD were collected, and the predictive mortality values of variables were analyzed.

Results

Of the 167 patients, 66.7% (44/66) hemodialysis (HD), 41.1% (21/51) pre-HD, and 32.0% (16/50) non-CKD patients had extrapulmonary TB. The pleura and lymph node were the common sites in CKD patients. Clinical presentations of cough and hemoptysis in CKD patients were less common than those in non-CKD patients, 13.7% (16/117) of CKD patients even not having any clinical symptoms. The positive rates of tuberculin skin test, TB-polymerase chain reaction and acid-fast bacilli in sputum in HD patients were lower than those in pre-HD and non-CKD patients (p<0.05). CKD patients were more prone to gastrointestinal and neurological side effects during anti-TB treatment. The mortality rates of non-CKD, pre-HD and HD patients was 6.1%, 31.9% and 37.3%, respectively. Multivariate Cox analysis revealed that age≥40 years (HR: 5.871; p=0.019), hypoalbuminemia (HR:2.879; p=0.004), CKD stage 4–5 (HR:4.719; p=0.018) and HD (HR:6.13; p=0.005) were associated with mortality.

Discussion

CKD patients with TB have atypical clinical manifestations and high mortality. Age, hypoalbuminemia, CKD stage 4–5, and HD were independent predictors of mortality.

Genitourinary Tuberculosis: A Comprehensive Review of a Neglected Manifestation in Low-Endemic Countries

Genitourinary tuberculosis (GUTB) represents a disease often underestimated by urological specialists, particularly in settings such as the European one, where the pathology is less frequent. Similar to other uncommon diseases at these latitudes, GUTB is a neglected clinical problem. In this light, the aim of this review is to give a comprehensive overview of GUTB in order to provide a useful tool for urologists who seldomly manage this disease. A non-systematic review of genitourinary tuberculosis was performed on relevant articles published from January 1990 to July 2021 using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials. GUTB represents up to a quarter of extrapulmonary tuberculosis (EPTB) cases. Diagnostic, therapeutic and surgical work-up have been deeply reviewed and summarized. The mass migration of refugees to Europe as well as the ease of international travel is gradually leading to an upsurge in urological diseases such as GUTB, which were previously only rarely encountered in some European countries. The poor TB knowledge of European urologists should be improved through medical education courses, webinars or telematic means.

Management of Mycobacterium tuberculosis Prosthetic Joint Infection: 2 Cases and Literature Review

Prosthetic joint infection caused by Mycobacterium tuberculosis (TBPJI) is uncommon but can be encountered in immunocompromised patients or those from tuberculosis-endemic regions. A lack of clinical suspicion and experience with TBPJI often leads to a delay in diagnosis. We report 2 cases of TBPJI in a Hungarian-Canadian and Iranian-Canadian immigrant, respectively. Both were treated with concurrent surgical and medical therapy. We also performed a literature review on TBPJI case reports, outlining their diagnosis and management.

Rapid Detection and Quantification of Mycobacterium tuberculosis DNA in Paraffinized Samples by Droplet Digital PCR: A Preliminary Study

Background: Rapid and reliable diagnosis of tuberculosis (TB) represents a diagnostic challenge in compartmentalized extrapulmonary TB infection because of the small number of mycobacteria (MTB) and the frequent lack of fresh samples to perform culture. Here, we estimate the performances of homemade droplet digital PCR (ddPCR)-based assays against culture in 89 biopsies, for those fresh and formalin-fixed and paraffin-embedded (FFPE) subsamples were available.

Methods: MTB diagnosis in fresh subsamples was performed by culture. Fresh subsamples were also analyzed for acid-fast bacilli smear-microscopy (AFB) and Xpert^® MTB/RIF (Xpert). MTB examination was repeated in blind in the 89 FFPE subsamples by in-house ddPCR assays targeting the IS6110 and rpoB. Analytical sensitivity of ddPCR assays was evaluated using serial dilution of H37Rv strain. Limit of detection (LOD) was calculated by probit analysis. Results were expressed in copies/10⁶ cells.

Results: IS6110 and rpoB ddPCR assays showed a good linear correlation between expected and observed values (R²: 0.9907 and 0.9743, respectively). Probit analyses predicted a LOD of 17 and 40 copies/10⁶ cells of MTB DNA for IS6110 and rpoB, respectively. Of the 89 biopsies, 68 were culture positive and 21 were culture negative. Considering mycobacterial culture as reference method, IS6110 assay yielded positive results in 67/68 culture-positive samples with a median interquartile range (IQR) of 1,680 (550–8,444) copies/10⁶ cells (sensitivity: 98.5%; accuracy: 98.9). These performances were superior to those reported by the rpoB assay in FFPE subsamples (sensitivity: 66.20%; accuracy: 74.1) and even superior to those reported by Xpert and AFB in fresh subsamples (sensitivity: 79.4 and 33.8%, respectively; accuracy: 84.3 and 49.4, respectively). When Xpert and AFB results were stratified according to mycobacterial load detected by rpoB and IS6110 ddPCR, bacterial load was lower in Xpert and AFB negative with respect to Xpert and AFB-positive samples (p = 0.003 and 0.01 for rpoB and p = 0.01 and 0.11 for IS6110), confirming the poor sensitivity of these methods in paucibacillary disease.

Conclusion: ddPCR provides highly sensitive, accurate, and rapid MTB diagnosis in FFPE samples, as defined by the high concordance between IS6110 assay and culture results. This approach can be safely introduced in clinical routine to accelerate MTB diagnosis mainly when culture results remain unavailable.

Tuberculosis in Poland in 2018

AIM OF THE STUDY

To evaluate the main features of tuberculosis (TB) epidemiology in 2018 in Poland and to compare with the situation in the EU/EEA countries.

METHODS

Analysis of case- based data on TB patients from National TB Register, data on anti-TB drug susceptibility testing results in cases notified in 2018, data from National Institute of Public Health- National Institute of Hygiene on HIV-positive subjects for whom TB was an AIDS-defining disease, data from Central Statistical Office on deaths from tuberculosis based on death certificates, data from the report " European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2020- 2018 data. Stockholm: European Centre for Disease Prevention and Control, 2020".

RESULTS

In 2018, 5487 TB cases were reported in Poland. The incidence rate was 14.3 cases per 100000, with large variability between voivodeships from 7.3 to 23.4 per 100 000. The mean annual decrease of TB incidence in 2014- 2018 was 3.8%. In 2018, 4852 cases were newly diagnosed with no history of previous treatment i.e. 12.6 per 100 000. 635 cases i.e. 1.7 per 100 000 - 11.6% of all registered subjects were previously treated for tuberculosis. In 2018, the number of all pulmonary tuberculosis cases was 5224 i.e. 13.7 per 100000. Pulmonary cases represented 95.2% of all TB cases. In 2018, 243 extrapulmonary TB cases were found i.e. 0.6 per 100 000. In the whole country there were 52 pediatric cases of tuberculosis. TB in children represented 0.9% of all cases notified in Poland in 2018. The incidence rates of tuberculosis were growing along with the age group from 0.9 per 100 000 among children to 24.7 per 100 000 among subjects in the age group 45-64 years (the highest incidence rate). In 2018, the incidence rate in the age group ≥65 years was 21.3 per 100 000. The TB incidence among men i.e. 21.0 per 100 000 was 2.6 times higher than among women i.e. 8.0 per 100 000. The biggest difference in the TB incidence between the two sex groups occurred in persons aged 55 to 59 years - 44.9 vs. 9.8 and in age group 60- 64 years - 43.7 vs. 10.2. The TB incidence in rural population was lower than in urban, respectively 13.4 per 100 000 and 14.9 per 100 000. The number of all registered culture positive TB cases was 4075. Pulmonary tuberculosis was bacteriologically confirmed in 3935 subjects. Cases confirmed by culture represented 74.3% of all TB cases and 75.3% of all pulmonary TB cases. The number of smear-positive pulmonary TB cases reported in 2018 was 2324 i.e. 6.1 per 100 000 accounting for 44.3% of all pulmonary TB cases and 59.1% of pulmonary TB cases confirmed by culture. In all patients with tuberculosis in Poland in 2018 there were 48 cases with MDR-TB (among them 14 foreigners) and 83 patients with resistance to isoniazid only, representing respectively 1.3% and 2.2% of cases with known DST results (DSTs were available in 90.7% of all culture-confirmed TB cases). In 2018, there were 97 patients of foreign origin among all cases of tuberculosis in Poland. TB was AIDS-indicative disease in 14 subjects with HIV co-infection. There were 490 deaths due to tuberculosis reported in 2017 - 1.3 per 100 000; 468 people died from pulmonary and 22 from extrapulmonary tuberculosis. Mortality among males - 2.1 per 100 000 - was 3.6 X higher than among females - 0.5. 40.2% of all TB deaths were cases 65 years old and older - 3.1 per 100 000. In 2017, there was no death from tuberculosis in children and no deaths in adolescents. In 2017, tuberculosis represented 0.1% of total mortality in Poland and 25.4% of mortality from infectious and parasitic diseases.

CONCLUSIONS

In 2018, the incidence of tuberculosis in Poland was lower than in 2017. Despite a continuous decline it is still higher than the average in the EU/EEA countries. The highest incidence rates were observed in older age groups. The participation of pediatric cases is smaller than average in the EU/EEA countries. The incidence in males was more than 2 times higher than in females. The impact of migration on the characteristics of tuberculosis in Poland is not substantial. In Poland, MDR-TB is less common than the average in the EU/EEA countries.

Tuberculosis Burden and Determinants of Treatment Outcomes According to Age in Brazil: A Nationwide Study of 896,314 Cases Reported Between 2010 and 2019

Approximately 1.4 million people die annually worldwide from tuberculosis. Large epidemiologic studies can identify determinants of unfavorable clinical outcomes according to age, which can guide public health policy implementation and clinical management to improve outcomes. We obtained data from the national tuberculosis case registry; data were reported to the Brazilian National Program (SINAN) between 2010 and 2019. Clinical and epidemiologic variables were compared between age groups (child: <10 years, young: 10–24years, adult: 25–64years, and elderly: ≥65years). Univariate comparisons were performed together with second-generation p-values. We applied a backward stepwise multivariable logistic regression model to identify characteristics in each age group associated with unfavorable TB treatment outcomes. There were 896,314 tuberculosis cases reported during the period. Tuberculosis incidence was highest among adult males, but the young males presented the highest growth rate during the period. Directly observed therapy (DOT) was associated with protection against unfavorable outcomes in all age groups. The use of alcohol, illicit drugs, and smoking, as well as occurrence of comorbidities, were significantly different between age groups. Lack of DOT, previous tuberculosis, race, location of tuberculosis disease, and HIV infection were independent risk factors for unfavorable outcome depending on the age group. The clinical and epidemiological risk factors for unfavorable tuberculosis treatment outcomes varied according to age in Brazil. DOT was associated with improved outcomes in all age groups. Incidence according to age and sex identified adults and young males as the groups that need prevention efforts. This supports implementation of DOT in all populations to improve tuberculosis outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Stillbirth as the primary manifestation of disseminated tuberculosis in a young immunocompetent mother with multiple perforations of the ileum

Tuberculosis (TB), a significant cause of morbidity and mortality worldwide, is particularly relevant in low/middle-income countries like India, where the disease is endemic. The female reproductive system is very vulnerable to this infection with, the clinical presentation being utterly silent in most patients. Symptoms of TB in pregnancy may initially be attributed to the gravidity itself besides temporary concealment of associated weight loss by the normally occurring weight gain during the pregnancy. Untreated TB may cause pregnancy loss by either placental damage or direct harm to both the mother and child. We report a case of latent disseminated TB in a young immunocompetent female that was revealed in the postpartum state (after full-term stillbirth delivery at home) as 20 ileal perforations secondary to intestinal TB. Due to ongoing sepsis and delayed presentation to the hospital, the patient could not be salvaged despite the best possible efforts.

Serum-Based Diagnosis of Pediatric Tuberculosis by Assay of Mycobacterium tuberculosis Factors: a Retrospective Cohort Study

Diagnosis of pediatric tuberculosis (TB) is often complicated by its nonspecific symptoms, paucibacillary nature, and the need for invasive specimen collection techniques. However, a recently reported assay that detects Mycobacterium tuberculosis virulence factors in serum can diagnose various TB manifestations, including paucibacillary TB cases, in adults with good sensitivity and specificity.

Diagnosis of pediatric tuberculosis (TB) is often complicated by its nonspecific symptoms, paucibacillary nature, and the need for invasive specimen collection techniques. However, a recently reported assay that detects Mycobacterium tuberculosis virulence factors in serum can diagnose various TB manifestations, including paucibacillary TB cases, in adults with good sensitivity and specificity. The current study examined the ability of this M. tuberculosis biomarker assay to diagnose pediatric TB using archived cryopreserved serum samples drawn from children ≤18 years of age who were screened for suspected TB as part of a prospective population-based active surveillance study. In this analysis, any detectable level of either of the M. tuberculosis virulence factors CFP-10 and ESAT-6 was considered direct evidence of TB. Serum samples from 105 children evaluated for TB (55 TB cases and 50 close contacts without TB) were analyzed. The results of this analysis yielded sensitivity of 85.5% (95% confidence interval [CI], 73.3 to 93.5). Similar diagnostic sensitivities were observed for culture-positive (87.5%; 95% CI, 67.6 to 97.3) and culture-negative (83.9%; 95% CI, 66.3 to 94.5) TB cases and for culture negative pulmonary (77.8%; 95% CI, 40.0 to 97.2) and extrapulmonary (86.4%; 95% CI, 65.1 to 97.1) TB cases. These results suggest that serum biomarker analysis holds significant promise for rapid and sensitive diagnosis of pediatric TB cases, including extrapulmonary or paucibacillary TB cases. The ability to use frozen samples for this analysis should also permit assays to be performed at central sites, without a requirement for strict timelines for sample analysis.

Cervical lymph node tuberculosis and TNF, IL8, IL10, IL12B and IFNG polymorphisms

Cervical lymph node tuberculosis (LNTB) is the most common manifestation of extrapulmonary tuberculosis, resulting from the interaction of environmental and genetic factors. The immune response against TB is regulated by several cytokines, which have single nucleotide polymorphisms (SNPs), leading to different levels of expression. The aim of this study was to evaluate the association of LNTB with the TNF, IL8, IL10, IL12B and IFNG gene polymorphisms in Mexican patients. We investigated the association of ten SNPs in 14 patients with LNTB and 138 healthy controls. Significant differences were found for the allele TNF-238A (P=0.03) and the genotypes TNF-238GA (P=0.03), IL8+396GG (P=0.01) and IL12B+1188CC (P=0.04). Allele IL8+781C showed some association trend (P=0.08). Haplotypes TNF-AA and IL10-GTA were of susceptibility, whereas haplotype IL8-ATT was of protection. No association was found with IFNG. The association of these polymorphisms with extrapulmonary TB was compared in different populations. Our results suggest that these cytokine SNPs may influence the manifestation of LNTB in Mexican patients; however, we are aware of the limitations of our study, so it is necessary to make a replica using a larger sample of patients, as well as an increased number of cytokines with SNPs.

The Benefit of Interferon-Gamma Release Assay for Diagnosis of Extrapulmonary Tuberculosis

BACKGROUND

there are many researches about IGRA in extrapulmonary Tuberculosis (TB), but there only few data from developing countries. This was the first research about the utility of IGRA in extrapulmonary TB performed in Indonesia as developing country with the 2nd most frequent of TB cases in the world. This study aimed to identify the advantage of IGRA examination in diagnosing extrapulmonary TB.

METHODS

eighty-four patients, presumed to have extrapulmonary TB were examined with IGRA and gold standard examination. The gold standard examination was performed by histopathologic examination, and tissue smear for acid-fast bacilli.

RESULTS

among 84 patients included in the study, 57 patients were tested positive with gold standard, where 50 patients among them were also tested positive with IGRA. Among 27 patients tested negative with gold standard, IGRA positive was found in 10 patients. Lymphadenitis was the most common manifestation of the extrapulmonary TB. Diagnostic test from IGRA for extrapulmonary TB found as follows: sensitivity 87,71%, specificity 63%, positive predictive value 83,33%, and negative predictive value 70,83%.

CONCLUSION

IGRA could be used as supporting tool in the diagnosis of extrapulmonary TB. The negative result, however, does not indicate absence of TB infection.

Tuberculosis in Poland in 2016

AIM OF THE STUDY

To evaluate the main features of TB epidemiology in 2016 in Poland and to compare with the situation in the EU/EEA countries.

METHODS

Analysis of case- based data on TB patients from National TB Register, data on anti-TB drug susceptibility testing results in cases notified in 2016, data from National Institute of Public Health- National Institute of Hygiene on cases of tuberculosis as AIDS-defining disease, data from Central Statistical Office on deaths from tuberculosis based on death certificates, data from ECDC report „ European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2018- 2016 data. Stockholm: European Centre for Disease Prevention and Control, 2018”.

RESULTS

In 2016, 6 444 TB cases were reported in Poland. The incidence rate was 16.8 cases per 100 000, with large variability between voivodships from 8.1 to 24.3 per 100 000. The average decline of TB incidence was 3.0% per year during 2012- 2016. 5 713 cases were new, never treated i.e. 14.9 per 100 000. 731 cases i.e. 1.9 per 100 000 – 11.3% of all registered subjects were previously treated. In 2016, 6 116 pulmonary tuberculosis cases occurred in Poland, equivalent to 15.9 per 100 000. Pulmonary cases represented 94.9% of all TB cases. The number of pulmonary TB cases with bacteriological confirmation was 4475 i.e. 12,0 per 100 000. In 2016, only 328 extrapulmonary TB cases were reported. Pediatric cases represented 1.6% of the total TB cases in Poland; 103 children with TB were notified. The incidence of tuberculosis has been growing along with the age group from 1.8 per 100 000 among children to 27.8 per 100 000 among patients aged 45 to 64 years. In the age group 65 years old and older the incidence was 26.0 per 100 000. The incidence among men i.e. 24.0 per 100 000 was >2 times higher than among women i.e. 10.0 per 100 000. The biggest difference in the TB incidence between the two sex groups occurred in persons aged 55 to 59 years – 51.9 vs. 11.5 and in subjects aged 60 to 64 years (45.9 vs. 11.7). The TB incidence in urban population was higher than in rural, respectively 17.3 per 100 000 and 15.9 per 100 000. In 2016, the number of all culture positive TB cases was 4619. Culture-confirmed cases represented 71.7% of all TB cases; culture-confirmed pulmonary TB – 73.2% of all pulmonary TB cases. In 2016, the number of smear-positive/culture positive pulmonary TB cases was 2612 (6.8 per 100 000) what represented 42.7% of all pulmonary TB cases. TB was initial AIDS indicative disease in 17 persons. In 2016, 46 cases with MDR-TB (among them 10 foreigners) and 101 patients with resistance solely to isoniazid were reported in Poland, representing respectively 1.1% and 2.4% of cases with known DST results (DSTs were done in 90.7% of all culture-confirmed TB cases). In 2016, there were 92 TB cases of foreign origin. In 2015, there were 537 deaths due to tuberculosis in Poland, which is equivalent to 1.4 deaths per 100 000 population; 520 people died from pulmonary and 17 from extrapulmonary tuberculosis. Mortality among males – 2.3 per 100 000 – was 3.8 x higher than among females – 0.6. The highest mortality rate was observed in subjects 65 years old and older – 3.3 per 100 000. There were no deaths from tuberculosis in children and adolescents. In 2015, TB mortality represented 0.14% of total mortality in Poland and 28.0% of mortality from infectious diseases.

CONCLUSIONS

In 2016, the incidence of tuberculosis in Poland was slightly higher than in 2015 and higher than the average in the EU/EEA countries. The highest incidence rates were observed in older age groups. The incidence in males was more than 2 times higher than in females. The impact of migration on the characteristics of tuberculosis in Poland is low. In Poland, tuberculosis in children, tuberculosis in persons infected with HIV and MDR-TB is less common than the average in the EU/EEA countries.

Epidemiological Characteristics and Clinical Outcome of HIV-Related Tuberculosis in a Population of TB Patients in South-western Nigeria

Tuberculosis (TB) is the second leading cause of death from infectious disease globally with its impact more dramatic in resource limited settings. Individuals with human immunodeficiency virus (HIV) infection who also develop tuberculosis represent a significant challenge to TB control. This study was carried out to determine the prevalence of TB–HIV coinfection and pattern of infection among TB patients. We also compared treatment outcome among coinfected patients with those not coinfected.

A six-year retrospective review of records of patients managed at the Tuberculosis Treatment Center of the LAUTECH Teaching Hospital, South-Western Nigeria from January 2009 to December 2014 was carried out.

One hundred and five (26.3%) of the 399 TB patients seen in the study period were coinfected with HIV. About 10% of the subjects had extrapulmonary tuberculosis. Treatment failure was significantly worse among patients who had both HIV and TB compared with those who had TB only (49.5% vs. 32%, p = 0.001). Death rate was also higher in the coinfected individuals implying a poorer clinical outcome.

High prevalence of TB–HIV coinfection and poor treatment outcome in this group of individuals, though predictable, calls for a more concerted effort in the management of TB–HIV coinfection.

Tuberculosis in Poland in 2015

AIM OF THE STUDY

To evaluate the main features of TB epidemiology in 2015 in Poland and to compare with the data on the same phenomena in the EU/EEA countries.

METHODS

Analysis of case – based data on TB patients from National TB Register, data on anti-TB drug susceptibility testing results in cases notified in 2015, data from National Institute of Public Health- National Institute of Hygiene on cases of tuberculosis as AIDS-defining disease, data from Central Statistical Office on deaths from tuberculosis based on death certificates, data from ECDC report „ European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2017. Stockholm: European Centre for Disease Prevention and Control, 2017”.

RESULTS

6430 TB cases were reported in Poland in 2015. The incidence rate was 16.7 cases per 100 000, with large variability between voivodeships from 8.3 to 26.5 per 100 000. The mean annual decrease of TB incidence in 2011- 2015 was 5.5%. 5757 cases were new, never treated i.e. 15.0 per 100 000. 673 cases i.e. 1.8 per 100 000 – 10.5% of all registered subjects were previously treated. The number of all notified pulmonary tuberculosis cases in 2015 was 6078 i.e. 15.8 per 100 000. Pulmonary cases represented 94.5% of all TB cases. The number of pulmonary TB cases with bacteriological confirmation was 4472 i.e. 11,6 per 100 000. In 2015, only 352 extrapulmonary TB cases were reported. Children accounted for 1.3% of all TB cases in Poland; 81 pediatric cases were notified. The incidence of tuberculosis has been growing along with the age group from 1.4 per 100 000 among children to 28.1 per 100 000 among patients aged 45 to 64 years. In the age group 65 years old and older the incidence was 26.9 per 100 000. The incidence among men i.e. 24.0 per 100 000 was >2 times higher than among women i.e. 9.9 per 100 000. The biggest difference in the TB incidence between the two sex groups occurred in persons aged 50 to 54 years – 45.6 vs. 12.4 and in subjects aged 55 to 59 years (53.3 vs. 12.8). The TB incidence in rural population was lower than in urban, respectively 16.5 per 100 000 and 16.9 per 100 000. The number of all registered culture positive TB cases, including cases previously treated, was 4630. Cultureconfirmed cases constituted 72.0% of all TB cases; culture-confirmed pulmonary TB – 73.6% of all pulmonary TB cases. The number of smear-positive/culture positive pulmonary TB cases reported in 2015 was 2714 i.e. 7.1 per 100 000 respectively what constituted 44.7% of all pulmonary TB cases. TB was initial AIDS indicative disease in 20 persons. In Poland in 2015 there were 35 cases with MDR-TB (among them 5 foreigners) and 95 patients with resistance solely to isoniazid, constituting respectively 0.8% and 2.3% of cases with known DST results (DSTs were done in 91.6% of all culture-confirmed TB cases). There were 52 cases of tuberculosis registered among foreigners in 2015. There were 526 deaths due to tuberculosis reported in 2014 – 1.4 per 100 000; 504 people died from pulmonary and 22 from extrapulmonary tuberculosis. Mortality among males – 2.2 per 100 000 – was 3.6 x higher than among females – 0.6. The highest mortality rate was in subjects 65 years old and older – 3.8 per 100 000. There were no deaths from tuberculosis in children. TB was cause of death in one adolescent. TB mortality in 2014 constituted 0.14% of total mortality in Poland and 27.4% of mortality from infectious diseases.

CONCLUSIONS

In Poland in 2015 the incidence of tuberculosis was lower than in the past but higher than the average in the EU/EEA countries. The highest incidence rates occurred in older age groups. The incidence in men was more than 2 times higher than in women. In Poland, tuberculosis in children, tuberculosis in persons infected with HIV and MDR-TB are less common than in the EU/EEA countries.

Clinical outcomes and mortality associated factors in patients infected with HIV receiving a presumptive anti-tuberculosis treatment in a tertiary level hospital in Burkina Faso

INTRODUCTION

Tuberculosis is the leading cause of death among people living with HIV/AIDS (PLHIV) in sub-Saharan Africa. In PLHIV, Smear-Negative Pulmonary Tuberculosis (SNPTB) and Extrapulmonary Tuberculosis (EPTB) are predominant. Presumptive anti-tuberculosis (anti-TB) treatment is often delayed leading to a high mortality rate.

OBJECTIVES

To investigate the clinical outcomes of presumptive anti-TB treatment in HIV patients suspected of having TB and to determine the factors associated with patients' death.

METHODS

We conducted a retrospective descriptive study from 1 January 2007 to 31 December 2008 in the Department of Internal Medicine of the Hospital Yalgado Ouédraogo on patients infected with HIV who received a presumptive anti-TB treatment. Defining patients with SNPTB or EPTB was based on the 2007 WHO's diagnostic algorithm of SNPTB and EPTB.

RESULTS

One hundred and sixteen patients of the 383 (30.2%) HIV patients hospitalized in this period were suspected of having TB. The average CD4 count was 86.1 cells/µl (SD = 42.3). A SNPTB was diagnosed in 67 patients (57.8%) and a EPTB in 49 patients (42.2%). The median length of hospitalization duration was 23.5 days. The average time of initiation of anti-TB treatment after admission was 22 days (SD = 9.2 days). Evolution during the hospital stay was favorable for 65 patients (56.0%), unfavorable for 48 patients (41.4% or 12.5% of all hospitalized patients), and 3 patients (2.6%) were treatment defaulters. In a multivariate analysis, hospitalization duration longer than 15 days and a delay of anti-TB treatment initiation of more than 30 days are independent factors associated with patients' deaths.

CONCLUSION

An urgent access to TB-diagnostic tools and a revision of the International algorithm for the diagnosis and treatment of SNPTB and EPTB in the context of HIV could help to reduce the delay of anti-TB treatment initiation and the mortality rate of PLHIV in sub-Saharan Africa.