Threefold Increase in the Number of Drug Resistant TB Cases after Introduction of Universal Drug Susceptibility Testing: Experiences from Two South India Districts

Background: In India, tuberculosis (TB) is a major public health problem, and the advent of drug resistance TB (DR-TB) has worsened the situation. The Revised National TB Control Programme (RNTCP) has introduced universal drug susceptibility testing (UDST) for all diagnosed TB cases in 2018. We conducted this study to know the advantage of implementing UDST when compared to selective testing existent in 2017 on key diagnostic cascade parameters and to identify the challenges in the implementation of UDST. Methods: The study was conducted in two districts of Karnataka, India during January 2017-December 2018. The quantitative part consisted of before-and-after design and the qualitative part consisted of descriptive design. Results: In 2017 (during selective testing/“before” period) out of the 2440 TB patients, 80 (3%) were diagnosed with Isoniazid and Rifampicin resistance patients;in contrast in 2018 (during UDST/“after” period) of the 5129 TB patients 258 (5%) were diagnosed with Isoniazid and Rifampicin resistance. However, the proportion of eligible patients tested for rifampicin resistance during the “after” period was 60% when compared to 100% during the “before” period and median turnaround time for testing was also longer during the “after” period when compared to the “before” period (32.5 days vs 27.5 days). Major reasons for these two gaps were found to be difficulties in collecting sputum specimens and transportation. Conclusion: The rollout of UDST has led to a three-fold increase in a number of DR-TB cases detected in the region. There is a need for the programme to increase the proportion tested for DST by increasing the laboratory capacity and address the challenges in sputum collection and transportation.

Pulmonary Tuberculosis in HIV-infected Patients Presenting with Normal Chest Radiograph and Negative Sputum Smear

Deaths due to Tuberculosis （TB） are high among the TB-HIV co-infected patients. Among PLHIV most of the instances the sputum smear is found to be negative for MTb. Chest X-rays also don＇t yield much diagnostic value mainly due to the advanced immune suppressed condition. This study makes an attempt to find out the utility of alternate staining methods such as Light Emitting Diode （LED）, Fluorescent Microscopy （FM） and solid culture in resource limited settings for effective diagnosis of TB among PLHIV. 2 sputum samples were collected from 102 successive presumptive TB cases, whose smear microscopy and X-Ray were negative for MTb among PLHIVs visiting ICTC at MGM hospital, Warangal, Telangana State, India. All the 102 samples were repeated with ZN microscopy and X-ray. Additionally LED and FM microscopy procedures were conducted with the NALC-NAOH concentration method. All the samples were inoculated on LJ medium for solid culture and all the positive cultures were subjected for biochemical test to identify phenotypic appearance, nitrate reduction, niacin and PNB susceptibility test for all the first line anti TB drugs as per standard guidelines. Samples found positive on microscopy were cross checked with Line probe assay （LPA）. All the 102 samples collected showed negative for MTb on ZN technique and negative for pulmonary TB on chest X-rays. 15 samples were positive for MTb both on LED and FM. LPA reconfirmed the MTb in all the 15 samples tested with 11 sensitive for both INH and Rifampicin, 3 INH mono resistant and I Rifmono resistance patterns. Of the 102 inoculations in LJ medium, 25 culture inoculations were positive for MTb growth and also were confirmed as MTb strains based on morphological, biochemical test and growth was seen after 4th week of inoculation. Of the 25 culture positives 20 were sensitive for INH and Rif, 4 INH mono resistant and 1 resistant to all first line anti TB drugs. In smear negative and chest X-ray negative presumptive TB cases, especially in immune compromised groups such as PLHIV, it is found to be useful to subject the sputum samples to LED and FM methods and at least solid culture wherever available. These methods clearly demonstrated additional yield over conventional ZN staining which can be recommended especially in the settings where high throughput equipment such as Xpert MTB/RIFor liquid culture is not available. These proactive measures can help in early diagnosis of TB which in turn can reduce mortality due to TB among PLHIV and break the chain of transmission of TB. Recommendations： Technology such as LED or FM microscopy can be advised for effective diagnosis of TB among Presumptive TB cases in PLHIV in settings where Xpert MTB/RIF is not available.

Tuberculous Otitis Media—A Rare Entity or a Missed Diagnosis

Objective: The aim of the study is to look for indicators of Tuberculous Otitis Media in all cases of chronic suppurative otitis media. Study Design: This is a retrospective study. Setting: This study was conducted in a tertiary care centre. Subjects and Methods: Detected cases of tuberculous otitis media (TBOM) cases studied retrospectively from January 2011 to December 2013 were included in the study. Investigations for tuberculosis were considered in the cases showing suspicious pale granulation tissue in the external auditory canal and middle ear and also in cases showing exuberant pale granulation tissue during mastoid surgery where Zeihl Nielson staining, histopathology, molecular genetic study was done. Cases showing positive result were included in the study. Results: During the study period 751 cases of CSOM were seen in outpatient room of which 18 cases of TBOM were diagnosed. Three patients were diagnosed preoperatively and 181 underwent surgery of which 15 cases were diagnosed positive, from the tissue obtained during the procedure. Direct smear was positive in four cases, concentration techniques in seven cases. Line probe assay was taken as diagnostic in all the cases. None of the cases were positive on histopathology. Conclusion: Tuberculous otitis media is often missed as the classical features are not seen in all cases of TBOM. The absence of these should not stop the clinician from diagnosing the disease. Suspicious tissue should therefore be tested properly to avoid missing the diagnosis and to prevent any complications.