[REASONS OF DELAYED DIAGNOSIS OF BLADDER TUBERCULOSIS]

The fourth, terminal, stage of bladder tuberculosis (BT) manifests itself in irreversible changes and requires surgical treatment.

OBJECTIVE

To identify the reasons for delayed diagnosis of this urogenital tuberculosis complication. Medical history of 26 urogenital tuberculosis patients with a complicated form of stage 4 BT, referred to the Novosibirsk TB Research Institute for reconstructive surgery were analysed. In 22 patients, bladder volume ranged from 55 to 100 ml, 4 patients previously underwent cystostomy due to extremely small bladder volume. Average duration of BT hidden in the guise of "urogenital infection" was 6.2 years. Patients were treated with norfloxacin (a total of 104 courses), ciprofloxacin (86 courses), amikacin (43 courses), nitroxoline (27 courses), third generation cephalosporins (32 courses), lomefloxacin (17 courses), levofloxacin (11 courses), Amoxicillin clavulanate (4 courses), ampicillin (2 courses). It was demonstrated that all cases of BT stage 4 were iatrogenic. Irreversible debilitating complications occurred due to suboptimal therapy, primarily due to administration of amikacin and fluoroquinolones for urogenital infections, which was tuberculosis in disguise. Absence of M. tuberculosis growth does not exclude tuberculosis; pathological specimens must be further examined at least by PCR. Interventional material must be mandatory examined histologically and stained by Ziehl-Neelsen method to identify M. tuberculosis. Effective and not masking tuberculosis, optimal therapy for urogenital infections includes fosfomycin, furazidin (nitrofurantoin), gentamicin, III generation cephalosporins (in outpatient settings dispersible form of efixime should be preferable).

[Revisiting the causes of low detection of M. tuberculosis in urine]

The evaluation of potential anti-TB activity and bactericidal activity against opportunistic enterobacteria in urine of healthy people using the automated BACTEC MGIT 960 system for cultivation and determination of drug resistance of mycobacteria and culture on solid media was performed. It has been established that the urine of healthy people do not have bactericidal activity against M. tuberculosis and E. coli in vitro. The one of the possible reasons for the low detection of the pathogen in urogenital tuberculosis--asymptomatic bacteriuria--was identified.

High mortality in adults hospitalized for active tuberculosis in a low HIV prevalence setting

BACKGROUND

This study aims to evaluate the outcomes of adults hospitalized for tuberculosis in a higher-income region with low HIV prevalence.

METHODS

A retrospective cohort study was conducted on all adults hospitalized for pulmonary and/or extrapulmonary tuberculosis in an acute-care hospital in Hong Kong during a two-year period. Microscopy and solid-medium culture were routinely performed. The diagnosis of tuberculosis was made by: (1) positive culture of M. tuberculosis, (2) positive M. tuberculosis PCR result, (3) histology findings of tuberculosis infection, and/or (4) typical clinico-radiological manifestations of tuberculosis which resolved after anti-TB treatment, in the absence of alternative diagnoses. Time to treatment ('early', started during initial admission; 'late', subsequent periods), reasons for delay, and short- and long-term survival were analyzed.

RESULTS

Altogether 349 patients were studied [median(IQR) age 62(48-77) years; non-HIV immunocompromised conditions 36.7%; HIV/AIDS 2.0%]. 57.9%, 16.3%, and 25.8% had pulmonary, extrapulmonary, and pulmonary-extrapulmonary tuberculosis respectively. 58.2% was smear-negative; 0.6% multidrug-resistant. 43.4% developed hypoxemia. Crude 90-day and 1-year all-cause mortality was 13.8% and 24.1% respectively. 57.6% and 35.8% received 'early' and 'late' treatment respectively, latter mostly culture-guided [median(IQR) intervals, 5(3-9) vs. 43(25-61) days]. Diagnosis was unknown before death in 6.6%. Smear-negativity, malignancy, chronic lung diseases, and prior exposure to fluoroquinolones (adjusted-OR 10.6, 95%CI 1.3-85.2) delayed diagnosis of tuberculosis. Failure to receive 'early' treatment independently predicted higher mortality (Cox-model, adjusted-HR 1.8, 95%CI 1.1-3.0).

CONCLUSIONS

Mortality of hospitalized tuberculosis patients is high. Newer approaches incorporating methods for rapid diagnosis and initiation of anti-tuberculous treatment are urgently required to improve outcomes.

Urinary polymerase chain reaction for diagnosis of urogenital tuberculosis

INTRODUCTION

The aim of this study was to evaluate diagnostic value of urinary polymerase chain reaction (PCR) in urogenital tuberculosis (UTB).

MATERIALS AND METHODS

In 33 patients with confirmed diagnosis of UTB by urine culture and/or acid-fast staining, clinical symptoms and laboratory and radiological findings were evaluated. For each patient, 3 consecutive urine samples were examined by PCR for Mycobacterium tuberculosis and the results were compared with the standard microbiological methods and radiological findings.

RESULTS

The mean interval between the appearance of the symptoms and the diagnosis was 12.3 +/- 12.2 months. Symptoms were irritative bladder symptoms such as dysuria and diurnal or nocturnal frequency (51.5%), flank pain (27.3%), microscopic hematuria (18.2%), gross hematuria (9.1%), and suprapubic pain (9.1%). The laboratory findings included hematuria (27.3%), pyuria (12.1%), and hematuria with pyuria (48.5%). Diagnosis of UTB was made in 19 patients by positive urine culture for MT in 19 patients (57.6%), positive acid-fast staining in 6 (18.2%), and both in 8 (24.2%). Intravenous urography showed abnormal findings in 16 patients (61.5%), including pyelocaliceal dilatation (26.9%), ureteral stricture and hydroureter (23.1%), multiple small caliceal deformities (15.4%), severe parenchymal destruction (11.5%), autonephrectomy (11.5%), and calcification (7.7%). Urinary PCR was positive in 16 patients (48.5%) and in 10 (62.5%) with abnormal findings on intravenous urography.

CONCLUSION

A high index of suspicion is necessary for diagnosis of UTB even in patients with nonspecific manifestations. Urinary PCR is recommended for instant diagnosis and screening before further examinations, but it cannot be the sole diagnostic modality for diagnosis of UTB.

Genitourinary tuberculosis in a medical center in southern Taiwan: an eleven-year experience

BACKGROUND AND PURPOSE

Genitourinary tuberculosis is the second most common disease form of extrapulmonary tuberculosis. This study analyzed the clinical characteristics and outcome in 31 patients with genitourinary tuberculosis treated between 1994 and 2004 at a tertiary medical center in southern Taiwan.

METHODS

Data were collected by chart review. Diagnosis was based on microbiological or histological proof plus compatible radiographic findings and clinical presentation.

RESULTS

This study included 14 men (45%) and 17 women (55%). Their ages ranged from 31 to 81 years (mean, 58.1 years). Genitourinary symptoms (83.9%) were more frequent than constitutional symptoms (35.5%). Pyuria plus hematuria with sterile culture (51.6%) was the most common finding. Only 25.8% of patients had a known history of pulmonary tuberculosis. Diagnosis was based on microbiological findings in 11 patients (35.5%), and by histological findings in 20 (64.5%) patients. Intravenous pyelography revealed abnormalities in 94% of patients and renal ultrasonography in 79.2%. Imaging studies were characteristic of advanced stage in most patients. Twenty-five percent of patients were classified as having treatment failure after at least 6 months of therapy. The treatment failure rate was higher in patients with positive microbiological findings (71.4%) than in those with histological findings alone (5.9%, p=0.003).

CONCLUSIONS

The high rate of treatment failure and advanced stage of disease at diagnosis are indicative of the challenge in the care of patients with genitourinary tuberculosis in Taiwan.

Tuberculous epididymitis: a case report and literature review

Tuberculous epididymitis is a rare urological disease difficult to diagnose. The conventional methods for diagnosis are often time-consuming and invasive. The combined use of scrotal magnetic resonance imaging (MRI) and urinary polymerase chain reaction (PCR)-based assay for mycobacterial DNA (the latter because of its high sensitivity and specificity to demonstrate mycobacterial DNA) is a valuable method for rapid diagnosis of tuberculous epididymitis. We report a 79-year-old man who was admitted with the chief complaints of bilateral scrotal swelling and pain. The combined use of scrotal MRI and urinary PCR allowed prompt diagnosis of tuberculous epididymitis and adequate antituberculous therapy.

[Detection of mycobacteria tuberculosis in patients with urogenital tuberculosis by PCR method]

The study was carried out in hospital patients as well as in outpatients at the National Centre of Tuberculosis and Lung Diseases of Georgia (2002-2004). The group consisting of 32 patients with tuberculosis of urogenital system has been studied (newly detected forms). Except clinical laboratory, culture and X-ray contrast methods, two additional methods were used in testing of this group of patients. The examination of their urine, at the same time, was carried out by the Polymerase Chain Reaction method in order to detect Kochi bacillus and by three-time bacterioscopy of urine for acid resistant bacteria. Mycobacterium tuberculosis in urine has been detected in 26 (81,25%) patients by PCR method, and by urine bacterioscopy--acid fast bacilli (AFB+) in 18 (56,25%) patients. The histo-morphological investigation of specimens obtained by surgery confirmed the TB diagnosis in all patients. This study on patients suspected of Tuberculosis of genital-urinary system gives us an opportunity to update the diagnostic algorithm by including the modern molecular methods. This algorithm will help in timely detection of Tuberculosis, in selection of adequate therapy and in prevention of the further progression of the disease.

[Sensitivity of PCR method for detection of mycobacteria tuberculosis in patients with lung tuberculosis]

Both hospitalized patients and outpatient clinic patients at the National Centre of Tuberculosis and Lung Diseases of Georgia have been investigated. The group of patients with the tuberculosis of urogenital system, has been studied (newly detected cases), 70 cases in total. The examination of the urine was carried out by the Polymerase Chain Reaction (PCR) method in order to detect Kochi bacillus and by three-time bacterioscopy of urine on acid resistant bacterium. Mycobacterium tuberculosis in urine has been detected in 57 (81,43%) patients by PCR method, and by urine bacterioscopy acid fast bacilli (AFB)(+) in 36 (51,43%) patients. 50 hospitalized patients were examined as a separate group. They had the tuberculosis of lungs and insignificant pathological changes in urogenital system. Among them there was active bacillus secretion in 45 cases by phlegm bacterioscopy AFB(+). Out of 50 patients the mycobacterium tuberculosis in urine was detected in 30 (60%) cases by PCR method. It should be mentioned that according to the urine two-time bacterioscopy, carried out on 50 patients, has not been detected AFB(-) bacillus secretion. It may be concluded that the PCR method is advantageous in detecting of Kochi bacillus in urine. Introduction of this method in medical practice will give us the possibility to determine the risk-group for development of tubercular changes in urinary system associated with lung tuberculosis, in order to control such patients and to carry out the adequate urological examinations.

[Isolation of infectious agent of extrapulmonary tuberculosis by different microbiological methods]

Microbiological research of 59 patients with extrapulmonary localization tuberculosis was conducted for exposition of tuberculosis mycobacterium. It was determined that the method of microscopy of smear painted by Ziel-Nilsen with preliminary treatment of pathological material in the way of "enrichment" using sodium bicarbonate gives more effective result, than the method of direct microscopy of smear painted according to Ziel-Nilsen. It indicates the possibility to use this method for early diagnostics of extrapulmonary tuberculosis, for exposing mycobacteria at its urinary-sexual location.

Urogenital infection by Mycobacterium bovis relapsing after 50 years

A 64-year-old man was referred to chest clinic after presenting initially with painless haematuria. Bladder biopsies showed granulomatous inflammation and subsequent urine cultures grew Mycobacterium bovis. He had been treated empirically for genito-urinary tuberculosis twice previously and on both occasions his haematuria ceased. Although the early hospital notes have been destroyed we believe this represents a very late and recurrent relapse of cystitis due to M. bovis.

[Microbiological and molecular genetic characterization of Mycobacterium tuberculosis strains isolated from patients with multiorgan and generalized tuberculosis]

The paper presents the microbiological and molecular genetic characteristics of Mycobacterium tuberculosis (MBT) isolated from multiple lesion foci in 26 patients with multiorgan and generalized tuberculosis. Cultures of MBT of the family Beijing were isolated from the pathological specimens taken from 17 (65.4%) patients; those with individual genotypes were in 9 (34.6%) patients. The study indicated that cultured MBT from different types of pathological material from 25 of the 26 patients had identical spoligotypes irrespective of their clinical diagnosis. At the same time minor profile IS6110 changes might occur in the Mycobacteria of a patient during persistence. It may be concluded that multiple foci of tuberculous affliction in the patients are of unique origin and have the mechanism of development, associated with endogenous reactivation of infection.

Genitourinary tuberculosis after renal transplantation: report of 3 cases and review

Mycobacterium tuberculosis infection of the genitourinary tract is an uncommon disease in renal transplant recipients and presentation is atypical. Genitourinary tuberculosis is associated with graft rejection, and this diagnosis should be considered for renal transplant recipients with unexplained fever and constitutional symptoms.

Rapid diagnosis of genitourinary tuberculosis by polymerase chain reaction and non-radioactive DNA hybridization

OBJECTIVE

To establish a polymerase chain reaction (PCR) assay for the rapid detection and identification of mycobacteria in urine, and to assess the value of such assay in routine laboratory diagnosis of genitourinary tuberculosis.

MATERIALS AND METHODS

Urine specimens from 1000 patients with clinical suspicion of urinary tuberculosis were examined. Two assays for the detection and identification of Mycobacterium tuberculosis (M. tuberculosis) complex and mycobacteria other than tuberculosis (MOTT) by non-radioactive DNA hybridization of PCR-product were applied. The first assay used PCR primers and probe derived from M. tuberculosis species-specific DNA insertion sequence, IS6110. The second utilized mycobacterium genus-specific sequence encoding ribosomal ribonucleic acid (16S rRNA). The results obtained by PCR were compared with those obtained by standard microbiological methods, acid-fast bacilli (AFB) stain and culture.

RESULTS

Compared with cultures, the sensitivity of AFB staining was 52.07% and the specificity was 96.7%. In comparison to the results of culture, the overall sensitivity and specificity of the IS6110-PCR assay was 95.59% and 98.12% respectively. While the corresponding results for the 16S rRNA gene-PCR were 87.05% and 98. 9%.

CONCLUSION

The high sensitivity and specificity in addition to the potential for rapid detection of mycobacteria, makes this test a useful tool in the clinical management of mycobacterial infection in urine. Urine specimens may contain M. tuberculosis and/or other mycobacteria; therefore, there are advantages in using genus-specific primers in parallel with species-specific primers in PCR assay.

Role of enzyme linked immunosorbent assay in the diagnosis of suspected cases of genito urinary tuberculosis

The aim of study was evaluation of the utility of ELISA test using A60 Antigen for rapid diagnosis of Genitourinary Tuberculosis in various age groups. ELISA test based on mycobacterial antigen A60 (Anda biological, France) was used to estimate specific IgG antibodies in the sera of fifty four suspected cases of Genito urinary tuberculosis. (GUT)Sera of 30 montoux negative healthy adults (age/sex matched) were taken as control by detecting IgG anti bodies to A60 antigen. It was concluded from this study that IgM was positive in 87.0% of cases.

[The recovery of atypical mycobacteria from patients with urogenital diseases]

In 76 patients with genitourinary disorders an identification was carried out of atypical mycobacteria from the pathological material with subsequent categorization thereof into different groups according to Rennieun's classification. There have been established different numbers of recovering atypical mycobacteria, tuberculosis mycobacteria and their myxts in different urological and genital disorders, such as tuberculosis and cyst of the kidney, tuberculosis of appendages, chronic pyelonephritis, adenoma of the prostate. The conducted studies showed that the bulk of atypical mycobacteria identified in the above-named patients belonged in group II (scotochromogenes) and IV (fast-growing) as per Rennieun's classification.

[Clinical study on 17 cases of genitourinary tuberculosis]

Between 1987 and 1995, 17 patients with genitourinary tuberculosis were treated at Iwate Prefectural Central Hospital. The incidence of newly diagnosed genitourinary tuberculosis was 17 out of 16,363 outpatients (0.1%) during the 9-year period. Twelve patients had urinary tuberculosis and genital as well as urinary organs were affected in 5. Six (35%) patients presented in their fifties and 5 (29%) each in their forties and sixties. Nine (53%) patients had irritative voiding symptoms as the chief complaint. Only 29% had a known history of extra-genitourinaty tuberculosis. In addition to the standard multidrug chemotherapy, nephrectomy was performed in 5 patients and orchiectomy in 2 with epididymal tuberculosis. The incidence of tuberculosis has recently increased in many parts of our country and more attention should be paid to genitourinary tuberculosis.

Rapid identification of Mycobacterium tuberculosis complex on urine samples by Gen-Probe amplification test

The aim of the study was to evaluate the applicability to urine samples of the Amplified Mycobacterium tuberculosis Direct Detection Test (AMTD), which is currently used to identify this organism in respiratory specimens within a few hours. The study was performed on 95 patients, comprising 35 subjects with a high index of suspicion for active tuberculosis of the urinary tract and 60 subjects with evidence of non-mycobacterial disease. One urine specimen from each subject was examined by microscopy, culture and AMTD. AMTD was positive in 38 specimens and negative in 57. Assuming culture as the reference standard, the sensitivity, specificity, positive predictive value and negative predictive value of AMTD were 100%, 91.93%, 86.84% and 100%, respectively. Reassessing the discrepancies between AMTD and culture by review of patients' charts, the sensitivity, specificity, positive predictive value and negative predictive value of AMTD were 100%, 93.44%, 89.47% and 100%. The results of the study as well as the characteristics of AMTD encourage its use for the rapid recognition of urinary tract tuberculosis, although its findings should be interpreted cautiously when the clinical picture is not consistent with an active tuberculosis.

[Analysis of restriction fragment length polymorphism (RFLP) of Mycobacterium tuberculosis strains isolated from patients with several episodes of tuberculosis]

Analysis of restriction fragment length polymorphism (RFLP), using a DNA probe directed against the insertion sequence IS6110, was applied to strains of Mycobacterium tuberculosis successively isolated from four patients. In order to determine the cause of recurrence in these patients, the RFLP patterns of the corresponding isolated were analyzed. The profils obtained from the strains isolated from each of the patients were identical, thus suggesting that a relapse, rather than an exogenous reinfection with a new strain, was the cause of recurrence. The RFLP patterns of successive isolated remained unchanged during periods of time ranging from 5 months to 7 years, and were not modified after development of rifampin resistance. These results demonstrate the stability of the polymorphism detected by the IS6110 probe. Therefore, RFLP analysis is a powerfull epidemiologic tool to distinguish relapse from exogenous reinfection.

Bovine genitourinary tuberculosis revisited

Bovine tuberculosis is now rare in the western world. We report a case of bovine genitourinary tuberculosis causing obstructive renal failure. This combination does not appear to have been previously reported.

[Detection of mycobacteria in tissue in urogenital tuberculosis]

121 tissue specimens of the urogenital systems (66 from the kidney, 39 from the epididymis and testis, 8 from the prostate, 4 from the bladder and 4 from the female genital tract) were examined by microscopy, culture and animal experiment on the presence of mycobacteria. In 37 of these specimens (30.6%) mycobacteria were demonstrated, 10 of that only by microscopy and in 27 cases by culture and/or animal experiment. Up to 20 weeks after onset of treatment mycobacteria were demonstrated from the kidney tissue of treated patients by the diagnostic methods mentioned above. After this time mycobacteria never could be demonstrated. There was no correlation between the histological findings and the mycobacteriological investigations. The investigation of tissue specimens on the presence of mycobacteria also from other organs of the urogenital tract is suitable method of the bacteriological proof of tuberculosis, especially in the absence or positive bacteriological findings from the urine or accessory gland secretion for the estimation of species and resistance of these bacteria.

[Optimization of the number of bacteriologic tests in the diagnosis of tuberculosis]

A retrospective analysis over three years in the Cantonal Hospital of Basel favours the continued use of acid-fast smears in suspected tuberculosis. 54% of pulmonary tuberculosis cases can already be diagnosed with acid-fast smears. Smears of gastric aspirates and urine specimens can usually be dispensed with, as the false-positive quotation is much too high (18% for gastric aspirates and 89% for urine specimens). Where there are sputum specimens available, no additional cultures of gastric aspirates are necessary. If pulmonary tuberculosis is diagnosed, cultures of urine specimens are recommended as a means of searching for (probable) urogenital infection.

[Urogenital-tuberculosis: pathogenesis, diagnostic approach, roentgenologic pathology, staging and remarks for differential diagnosis (author's transl)]

The diagnostic tactics in the clarification of urogenital tuberculosis are referred to the changes for the individual examinations mentioned. Some tables show the results of radiological investigations on 200 patients with proved renal tuberculosis, the extend of the triple staging proposed by us being specified. In addition to expositions on the radiopathology of urogenital tuberculosis, the differential diagnosis is indicated, its focus lying in the comparsion of 118 patients with clinical-bacteriological and/or histologically confirmed non-specific chronic pyelonephritis. The comparison of patients from two 3-year groups 1959-1961 and 1971-1973 as well as between natives and foreigners shows a change in the clinical radiological picture of renal tuberculosis.

Sensitivity studies in bacteriologic diagnosis of urinary tuberculosis

The identification of Mycobacterium tuberculosis organisms is insensitive. This in vitro investigation compares the sensitivity of Ziehl-Neelsen and fluorochrome staining techniques after two and ten hours of incubation with standard culture techniques. The culture methods were persistently more sensitive than the stain techniques. Both stain techniques were of equal sensitivity. Ten hours incubation reduces the sensitivity of the staining techniques but does not alter the sensitivity of the culture methods.