Diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients:A mini review for clinicians

Among critically ill patients,severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality.Yet,it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the disease.In addition,management of severe pulmonary and extrapulmonary tuberculosis is complicated given the high risk of drug-drug interactions,drug-disease interactions,and adverse drug reactions.To help clinicians acquire an up-to-date approach to severe tuberculosis,this paper will provide a narrative review of contemporary diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients.

From immunology to artificial intelligence: revolutionizing latent tuberculosis infection diagnosis with machine learning

Latent tuberculosis infection(LTBI)has become a major source of active tuberculosis(ATB).Although the tuberculin skin test and interferon-gamma release assay can be used to diagnose LTBI,these methods can only differentiate infected individuals from healthy ones but cannot discriminate between LTBI and ATB.Thus,the diagnosis of LTBI faces many challenges,such as the lack of effective biomarkers from Mycobacterium tuberculosis(MTB)for distinguishing LTBI,the low diagnostic efficacy of biomarkers derived from the human host,and the absence of a gold standard to differentiate between LTBI and ATB.Sputum culture,as the gold standard for diagnosing tuberculosis,is time-consuming and cannot distinguish between ATB and LTBI.In this article,we review the pathogenesis of MTB and the immune mechanisms of the host in LTBI,including the innate and adaptive immune responses,multiple immune evasion mechanisms of MTB,and epigenetic regulation.Based on this knowledge,we summarize the current status and challenges in diagnosing LTBI and present the application of machine learning(ML)in LTBI diagnosis,as well as the advantages and limitations of ML in this context.Finally,we discuss the future development directions of ML applied to LTBI diagnosis.

Primary extrapulmonary tuberculosis diagnosis warrants extraprecautious pulmonary tuberculosis exclusion workup

This editorial article takes an opportunity to apprehend the diagnostic challenges of primary gastrointestinal tuberculosis(an uncommon extrapulmonary tuberculosis condition)utilizing the recently published case report of a young male with prolonged gastrointestinal symptoms and weight loss who received intermittent anti-tubercular treatment and underwent operative interventions to relieve gastric outlet obstruction.The diagnosis chiefly relied on high-end examinations,like computed tomography scans and histopathological evaluation of postoperatively resected bowel tissue,which wasn't preceded by an all-inclusive stepwise primary pulmonary tuberculosis exclusion approach that usually begins with a detailed tuberculosis-pertinent history acquisition.Given the geographic locations where the patient had been(and/or treated),pivotal consideration of tuberculosis-associated endemicities in those regions,like human immunodeficiency virus(HIV)infection,might have improved the case description.The obtainment of HIV-relevant histories,like intravenous drug use and sexual practice,are good places to start.The sputum bacteriology also seems imperative to rule out atypical Mycobacterium species infection because of its clinico-radiohistopathological resemblance with pulmonary Mycobacterium tuberculosis.Altogether,this editorial aims to underscore that primary extrapulmonary tuberculosis diagnosis should comprise an elaborative,comprehensive,systematic,and stepwise primary pulmonary Mycobacterium tuberculosis exclusion workup.

Effectiveness of Histopathological Examination of Ultrasound-guided Puncture Biopsy Samples for Diagnosis of Extrapulmonary Tuberculosis

Objective To evaluate the diagnostic value of histopathological examination of ultrasound-guided puncture biopsy samples in extrapulmonary tuberculosis(EPTB).Methods This study was conducted at the Shanghai Public Health Clinical Center.A total of 115patients underwent ultrasound-guided puncture biopsy,followed by MGIT 960 culture(culture),smear,Gene Xpert MTB/RIF(Xpert),and histopathological examination.These assays were performed to evaluate their effectiveness in diagnosing EPTB in comparison to two different diagnostic criteria:liquid culture and composite reference standard(CRS).Results When CRS was used as the reference standard,the sensitivity and specificity of culture,smear,Xpert,and histopathological examination were(44.83%,89.29%),(51.72%,89.29%),(70.11%,96.43%),and(85.06%,82.14%),respectively.Based on liquid culture tests,the sensitivity and specificity of smear,Xpert,and pathological examination were(66.67%,72.60%),(83.33%,63.01%),and(92.86%,45.21%),respectively.Histopathological examination showed the highest sensitivity but lowest specificity.Further,we found that the combination of Xpert and histopathological examination showed a sensitivity of 90.80%and a specificity of 89.29%.Conclusion Ultrasound-guided puncture sampling is safe and effective for the diagnosis of EPTB.Compared with culture,smear,and Xpert,histopathological examination showed higher sensitivity but lower specificity.The combination of histopathology with Xpert showed the best performance characteristics.

Differential diagnosis of Crohn’s disease and intestinal tuberculosis based on ATR-FTIR spectroscopy combined with machine learning

BACKGROUND Crohn’s disease(CD)is often misdiagnosed as intestinal tuberculosis(ITB).However,the treatment and prognosis of these two diseases are dramatically different.Therefore,it is important to develop a method to identify CD and ITB with high accuracy,specificity,and speed.AIM To develop a method to identify CD and ITB with high accuracy,specificity,and speed.METHODS A total of 72 paraffin wax-embedded tissue sections were pathologically and clinically diagnosed as CD or ITB.Paraffin wax-embedded tissue sections were attached to a metal coating and measured using attenuated total reflectance fourier transform infrared spectroscopy at mid-infrared wavelengths combined with XGBoost for differential diagnosis.RESULTS The results showed that the paraffin wax-embedded specimens of CD and ITB were significantly different in their spectral signals at 1074 cm^(-1) and 1234 cm^(-1) bands,and the differential diagnosis model based on spectral characteristics combined with machine learning showed accuracy,specificity,and sensitivity of 91.84%,92.59%,and 90.90%,respectively,for the differential diagnosis of CD and ITB.CONCLUSION Information on the mid-infrared region can reveal the different histological components of CD and ITB at the molecular level,and spectral analysis combined with machine learning to establish a diagnostic model is expected to become a new method for the differential diagnosis of CD and ITB.

Unveiling the Threat: Case Reports of Extra-Pulmonary Tuberculosis among Sanctuary Chimpanzees

Primate sanctuaries across Africa play a pivotal role in the rescue and rehabilitation of confiscated and rescued wild primates, many of whom have had extensive contact with humans prior to their arrival and throughout the rehabilitation process, heightening the risk of disease transmission. While tuberculosis is not naturally occurring in free-living chimpanzees, it has been extensively observed in captive primates that have been in close proximity to humans or other captive primates infected with Mycobacterium tuberculosis. This case report delves into an outbreak of extra-pulmonary tuberculosis among juvenile chimpanzees within a sanctuary, detailing the associated diagnostic challenges and treatment approaches. The five cases had close contact with a caregiver infected with tuberculosis, subsequently transmitting the infection to other in-contact chimpanzees. Prolonged treatment, employing the human protocol of quadri-therapy (rifampicin, isoniazid, pyrazinamide, and ethambutol), followed by bi-therapy (rifampicin and isoniazid), resulted in complete resolution for all five cases. These cases underscore the critical importance of maintaining high levels of biosecurity, implementing effective quarantine measures, and adhering to strict hygiene practices when working with non-human primates.

Investigation of the Clinical Diagnostic Significance of the T-Cell Test for Tuberculosis combined with Erythrocyte Sedimentation Test in Pulmonary Tuberculosis

Objective:To investigate the clinical diagnostic significance of peripheral blood T-cell test(T-spot test)for tuberculosis(TB)infection combined with erythrocyte sedimentation rate(ESR)in pulmonary TB.Methods:41 patients with a clinical diagnosis of TB during hospitalization from January 2020 to April 2023 in our hospital were selected as the experimental group,and 45 patients without TB(bronchopneumonia patients)were selected as the control group.The diagnostic specificity,sensitivity,and accuracy of the T-spot TB test,ESR test,and the combined test of the two were calculated respectively.Results:The sensitivity,specificity,and accuracy of the T-spot TB test combined with ESR for the diagnosis of TB in the experimental group were significantly higher than the individual results of the T-spot TB test and ESR test alone(P<0.05).Conclusion:The T-spot TB test combined with the ESR test for TB diagnosis has greater clinical value than carrying out the tests individually.

Diagnosis of abdominal tuberculosis:Experience from 11 cases and review of the literature

AIM:To analyze the experience within our hospital and to review the literature so as to establish the best means of diagnosis of abdominal tuberculosis. METHODS:The records of 11 patients (4 males,7 females, mean age 39 years,range 18-65 years) diagnosed with abdominal tuberculosis in Harran University Hospital between January 1996 and October 2003 were analyzed retrospectively and the literature was reviewed. RESULTS:Ascites was present in all cases.Other common findings were weight loss (81%),weakness (81%),abdominal mass (72%),abdominal pain (72%),abdominal distension (63%),anorexia (45%) and night sweat (36%).The average hemoglobin was 8.2 g/dL and the average FAR was 50 mm/h (range 30-125).Elevated levels of cancer antigen CA-125 were determined in four patients.Abdominal ultrasound showed abnormalities in all cases:ascites in all,tuboovarian mass in five,omental thickening in 3,and enlarged lymph nodes (mesenteric,para-aortic) in 2.CT scans showed ascites in all,pelvic mass in 5,retroperitoneal lymphadenopathy in 4,mesenteric stranding in 4,omental stranding in 3, bowel wall thickening in 2 and mesenteric lymphadenopathy in 2.Only one patient had a chest radiograph suggestive of a new TB lesion.Two had a positive family history of pulmonary TB.None had acid-fast bacilli (AFB) in the sputum and the tuberculin test was positive in only two.Laparotomy was performed in 6 cases,laparoscopy in 4 and ultrasound- guided fine needle aspiration in 2.In those patients subjected to operation,the findings were multiple diffuse involvement of the visceral and parietal peritoneum,white ‘miliary nodules’or plaques,enlarged lymph nodes,ascites, ‘violin string’fibrinous strands,and omental thickening. Biopsy specimens showed granulomas,while ascitic fluid showed numerous lymphocytes.Both were negative for acid-fast bacilli by staining.PCR of ascitic fluid was positive for Mycobactenum tuberculosis ( M.tuberculosis) in all cases. CONCLUSION:Abdominal TB should be considered in all cases with ascites.Our experience suggests that PCR of ascitic fluid obtained by ultrasound-guided fine needle aspiration is a reliable method for its diagnosis and should at least be attempted before surgical intervention.

Diagnosis of Crohn's disease in India where tuberculosis is widely prevalent

AIM:To define the parameters that positively predict diagnosis of Crohn's disease (CD) and differentiate it from gastrointestinal tuberculosis (GITB). METHODS:This prospective study over 3 years was carried out in the consecutive Indian patients with definite diagnosis of CD and equal numbers of patients with definite diagnosis of GITB. Demographic, clinical, laboratory, morphological and histological features were noted in all the patients. Serological tests such as p-ANCA, c-ANCA, IgA ASCA and IgG ASCA, were performed. Endoscopic biopsy and/or surgical tissue specimens were subjected to smear and culture for acid-fast bacilli (AFB) and tissue polymerase chain reaction for tuberculosis (TB PCR). Diagnosis of CD and GITB was based on the standard criteria. Data were analyzed using univariate Chi-square test and multiple logistic regression (MLR). RESULTS:The study is comprised of 26 patients with CD (age 36.6 ± 8.6 year, male:female, 16:10) and 26 patients with GITB (age 37.2 ± 9.6 year, male:female, 15:11). The following clinical variables between the two groups (CD vs TB) were significant in univariate analysis:duration of symptoms (58.1 ± 9.8 vs 7.2 ± 3.4 mo), diarrhoea (69.2% vs 34.6%), bleeding per rectum (30.7% vs 3.8%), fever (23.1% vs 69.2%), ascites (7.7% vs 34.6%) and extra-intestinal manifestations of inflammatory bowel disease (61.5% vs 23.1%). Of these, all except ascites and extra-colonic manifestations were found statistically significant by MLR. Accuracy of predicting CD was 84.62% based on the fever, bleeding P/R, diarrhoea and duration of symptoms while it was 63.4% when histology was reported as inflammatory bowel disease and 42.3% when there was recurrence of disease after surgery. Accuracy of predicting GITB was 73.1% when there was co-existing pulmonary lesions and/or abdominal lymphadenopathy;75% when tuberculosis was reported in histology;63.4% when granuloma was found in histology;82.6% when TB PCR was positive;and 61.5% when smear and/ or culture was positive for AFB. Serological test was not useful in differentiation of CD from GITB. Positivity rates for CD and GITB were:p-ANCA-3.8% and 3.8%, c-ANCA-3.8% and 0%, IgA ASCA-38.4% and 23.1%, and IgG ASCA-38.4% and 42.3%, respectively. CONCLUSION:Simple clinical parameters like fever, bleeding P/R, diarrhoea and duration of symptoms have the highest accuracy in differentiating CD from GITB.

Profile of Extra-Pulmonary Tuberculosis in Internal Medicine

Introduction: Tuberculosis is an infectious disease that mainly affects the lung. Extrapulmonary localizations are a reason for hospitalization in our health facilities. The objective of this study was to describe the epidemiological, clinical, paraclinical and evolutionary aspects of extra pulmonary tuberculosis (EPT) at the Abass Ndao Hospital Center. Patients and Methods: This was a descriptive cross-sectional study conducted over a period of 11 years (January 1, 2010 to December 30, 2021). All patients with extrapulmonary tuberculosis hospitalized in the department of internal medicine during the recruitment period were included. Results: Fifty-two (52) patients were collected. The year 2019 recorded the most cases 23.08% (n = 20). The mean age of the patients was 40.56 ± 18.24 years. The age group 20 - 34 years 42.31% (n = 22) was the most represented. Females were in the majority 61.54% (n = 32) with a sex ratio (M/F) was 0.63. Housewives were in the majority 40.38% (n = 21). 60.87% of the cases (n = 14) came from a health facility. 38.46% of the cases had been infected. 21.74% (n = 9) were smokers. The reasons for consultation were dominated by fever (67.44%), AEG (62.79%) and cough (41.86%). Eighteen patients (40.91%) had fever. The mean time to consultation was 77.37 ± 90.3 days with extremes of 3 and 365 days. The median was 45 days. More than half of the patients 61.90% (n = 26) had anemia. Positive retroviral serology was noted in 21.43% of cases. All patients had a CRP greater than 6. More than half of the patients 51.92% (n = 27) had multifocal tuberculosis. The peritoneum 44.23% (n = 23) was the main organ affected. The average hospital stay was 9.8 ± 4.9 days with extremes of 1 and 19 days. All patients had received the protocol in force at the national level. Death was noted in 4 patients (9.52%). Conclusion: EPT is characterized in our context by a notorious diagnostic difficulty due to the multiplicity of clinical presentations, the complexity of explorations, and the problems of differential diagnosis notably with other granulomatosis, systemic lupus and cancers. This difficulty is reflected in the low rate of diagnosis with a paraclinical argument of certainty and in the long diagnostic delays.

Delayed diagnosis and comprehensive treatment of cutaneous tuberculosis:A case report

BACKGROUND Tuberculosis(TB)is a widespread infectious disease,with an incidence that is increasing worldwide.Cutaneous TB(CTB)occurs rarely,accounting for less than 1%of all TB cases.Due to the clinical presentation and diagnostic difficulties,CTB is often clinically neglected and misdiagnosed.CASE SUMMARY A 32-year-old man underwent several debridement surgeries and skin flap transplantation after trauma.The wound remained unhealed,accompanied by sinus formation.According to empirical judgment,T-cell spot of TB test,and bacterial culture of pyogenic fluids,he was diagnosed with CTB due to infection with exogenous Mycobacterium tuberculosis.A comprehensive anti-TB regimen that included isoniazid,rifampicin,ethambutol,and pyrazinamide was applied.The sinus was filled with a hydrophilic fiber-containing silver dressing,and woundprotecting sponges were applied to part of the wound.The wound healed after 40 d.No ulceration was found within 2 mo after discharge;further follow-up will be conducted.CONCLUSION A non-healing wound may be caused by TB infection.Comprehensive treatment of CTB is effective.

Gastrointestinal tuberculosis:Diagnostic approaches for this uncommon pathology

A case report entitled“Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction”recently published in the World Journal of Clinical Cases presented a rare cause of gastric outlet obstruction and highlighted the atypical manner in which gastrointestinal tuberculosis(TB)can present.The literature with regards to this rare pathology is limited to case reports and case series with the largest being published using data from between 2003 and 2013.However,since then the diagnostic tools available have significantly changed with more modern and increasingly accurate tests now available.This editorial reviews the current state of the art with regards to diagnosis in gastrointestinal TB.

Clinical Evaluation of Two Interferon-Gamma Release Assays for Diagnostic Tests of Tuberculosis Infection in a Tertiary Hospital: Clinical Evaluation of Two IGRAs for TB Infection

Background: The aim of this study was to evaluate the usefulness of two interferon-gamma release assays (IGRAs) (QuantiFERON-TB Plus (QFT-plus) and T-SPOT.TB assay) for patients suspected of having tuberculosis (TB) infection as supportive methods for diagnosing TB. Patients and Methods: The subjects consisted of 45 patients who required clinical differentiation of TB disease from June 2019 to August 2023. The final clinical diagnoses were: 14 patients with active TB disease, 4 with latent TB infection (LTBI), 17 with old (cured) TB disease, and 10 with pulmonary nontuberculous mycobacterial (NTM) disease. We used the two IGRAs for these patients and evaluated the data according to the manufacturer’s guidelines for interpretation or FDA-approved cutoffs. Results: Among the total of 14 patients with active TB disease (mean age: 64 years old, male: 9, and female: 5), a positive response was noted in 10 patients (71%) on QFT-plus and 9 (64%) on T-SPOT.TB. Four patients with a negative response on QFT-plus and T-SPOT.TB were elderly or cancer patients with lymphocytopenia or hypoalbuminemia. All four patients with LTBI showed a positive response (100%) on both QFT-plus and T-SPOT.TB. Among the seventeen patients with old (cured) TB disease, a positive response was noted in 8 patients (47%) on QFT-plus and 9 (53%) on T-SPOT.TB. All patients with pulmonary NTM disease showed a negative response on both QFT-plus and T-SPOT.TB. Conclusions: A false-negative response on QFT-plus as well as T-SPOT.TB was recognized in elderly patients and patients with an immunosuppressed condition, and half of patients with old (cured) TB showed no negative conversion after the completion of treatment through this study. Although it was recently reported that the positive response rate on QFT-plus of patients with active TB disease was high, we consider it necessary to be careful in diagnosing TB infection using IGRAs for patients with severe underlying diseases in a tertiary hospital based on the results.

Comprehensive review on the diagnostic strategies for esophageal tuberculosis:the role of endoscopic ultrasonography

Esophageal tuberculosis(ET)is a relatively rare clinical condition,characterized by often atypical clinical features.The lack of specificity in diagnostic methods,such as esophagogastroduodenoscopy and various imaging techniques,frequently leads to misdiagnosis and inappropriate treatments.Compared to esophagogastroduodenoscopy,endoscopic ultrasonography(EUS)offers a more comprehensive examination of esophageal tuberculosis lesions,including the extent of wall layer involvement and the internal structure characteristics of the lesions.Furthermore,when necessary,endoscopic ultrasonography-guided fine-needle aspiration can be employed to acquire deeper pathological tissue,significantly aiding diagnosis.When combined with the patient’s clinical presentation,endoscopic findings,and pathological features,EUS plays a crucial role in the definitive diagnosis of ET and in the differential diagnosis process.This article meticulously reviews both national and international literature to summarize the relevant features of ET,with a focus on its appearance under EUS,and to highlight the clinical value of EUS in enhancing the diagnosis of ET and in distinguishing it from other conditions.The aim is to offer guidance for the accurate diagnosis of ET.

Evaluation of Xpert MTB/RIF Ultra for Diagnosis of Extrapulmonary Tuberculosis: A Retrospective Analysis in a Low-Tuberculosis Prevalence Setting

Background: Extrapulmonary tuberculosis (EPTB) remains difficult to diagnose because the clinical specimens to be examined are often paucibacillary and obtained with difficulty from inaccessible sites. An updated Xpert® MTB/RIF Ultra (Ultra) test has been designed and licensed to improve sensitivity in the detection of Mycobacterium tuberculosis complex. The aim of the present study is to evaluate the performance of Ultra assay for the clinical diagnosis of EPTB in a low tuberculosis prevalence country. Methods: A retrospective analysis was performed at “A. O dei Colli” of Naples on consecutive extrapulmonary specimens for EPTB across a three-year period. All different types of extrapulmonary specimens were tested for EPTB by smear microscopy, culture and Ultra assay in accordance with relevant guidelines. Results: A total of 606 EPTB samples, 561 culture negative EPTB and 45 culture positive EPTB were included. Using culture as reference standard, the overall sensitivities and specificities of Ultra assay were 95.6% (95% CI 84.8 - 99.5) and 97.5% (95% CI 95.8 - 98.6) respectively. Sensitivity and specificity of Ultra for individual category of specimens were also performed. Conclusion: In a low-tuberculosis prevalence setting, Ultra assay confirms to have a good performance in the diagnosis of EPTB for all different extrapulmonary samples.

Pleural Fluid Alkaline Phosphate Levels to Differentiate between Tuberculosis and Malignant Pleural Effusion a Tertiary Care Experience

Introduction: Pleural effusion (PF) is a common clinical presentation in several diseases. Tuberculosis is one of the most frequent causes of exudative pleural effusions in immunocompetent patients. Tuberculosis is the leading cause of morbidity and mortality from an infectious disease in developing countries. Pakistan is ranked fifth in the world in terms of tuberculosis high-burden countries. Various pleural fluid parameters have been used to identify the cause of pleural effusion. It has been discovered that tuberculous pleural effusions had a greater alkaline phosphatase (ALP) concentration than transudative effusions. This study used pleural fluid alkaline phosphatase levels to distinguish between tuberculous pleural effusion and malignant pleural effusion because there is little information from tuberculosis-high burden nations like Pakistan. Study Design: A descriptive cross-sectional study conducted at the Jinnah Postgraduate Medical Center in Karachi between October 2016 and October 2017. Material and Methods: The study comprised all patients who were admitted to the department of chest medicine at Jinnah post graduate medical centre (JPMC) of either gender between the ages of 18 and 70 who had exudative lymphocytic pleural effusions lasting two weeks or more included in the study. Non probability consecutive sampling was used to collect data. Patients who have tonsillitis, pharyngitis, pneumonia, asthma, Chronic obstructive pulmonary disease (COPD), or a history of hemoptysis, Bleeding disorders like, platelet function disorder, thrombocytopenia, Liver cirrhosis and Pregnant women were excluded. Parents’ informed consent was obtained after being informed of the study’s protocol, hazards, and advantages. Each patient had their level of pleural fluid alkaline phosphate (PALP) assessed. In order to evaluate the patient’s pleural effusion, a pre-made questionnaire was used. All the collected data were entered into the SPSS 20. An independent sample t-test was used to recognize alkaline phosphate levels association with pleural fluid secondary to tuberculosis or malignancy. Results: In this Descriptive Cross-Sectional Study, the total of 156 patients with age Mean ± SD of was 41.96 ± 17.05 years. The majority of patients 110 (70.5%) were male and 46 (29.5%) were female. Advanced age was associated with raised pleural fluid alkaline phosphatase. The difference of pleural fluid alkaline phosphate level between tuberculous v/s malignant group was found to be (38.03 ± 45.97) v/s (82.77 ± 61.80) respectively with P-value (P = 0.0001). Conclusion: Malignant pleural effusions had elevated PALP when compared to tuberculous pleural effusions in exudative lymphocytic pleural effusions;better differences are seen in older ages and shorter disease durations.

Routine diagnosis of intestinal tuberculosis and Crohn's disease in Southern India

AIM:To investigate whether routinely measured clinical variables could aid in differentiating intestinal tuberculosis(ITB)from Crohn’s disease(CD).METHODS:ITB and CD patients were prospectively included at four South Indian medical centres from October 2009 to July 2012.Routine investigations included case history,physical examination,blood biochemistry,ileocolonoscopy and histopathological examination of biopsies.Patients were followed-up after 2 and 6 mo of treatment.The diagnosis of ITB or CD was re-evaluated after 2 mo of antituberculous chemotherapy or immune suppressive therapy respectively,based on improvement in signs,symptoms and laboratory variables.This study was considered to be an exploratory analysis.Clinical,endoscopic and histopathological features recorded at the time of inclusion were subject to univariate analyses.Disease variables with sufficient number of recordings and P<0.05 were entered into logistic regression models,adjusted for known confounders.Finally,we calculated the odds ratios with respective confidence intervals for variables associated with either ITB or CD.RESULTS:This study included 38 ITB and 37 CD patients.Overall,ITB patients had the lowest body mass index(19.6 vs 22.7,P=0.01)and more commonly reported weight loss(73%vs 38%,P<0.01),watery diarrhoea(64%vs 33%,P=0.01)and rural domicile(58%vs 35%,P<0.05).Endoscopy typically showed mucosal nodularity(17/31 vs 2/37,P<0.01)and histopathology more frequently showed granulomas(10/30vs 2/35,P<0.01).The CD patients more frequently reported malaise(87%vs 64%,P=0.03),nausea(84%vs 56%,P=0.01),pain in the right lower abdominal quadrant on examination(90%vs 54%,P<0.01)and urban domicile(65%vs 42%,P<0.05).In CD,endoscopy typically showed involvement of multiple intestinal segments(27/37 vs 9/31,P<0.01).Using logistic regression analysis we found weight loss and nodularity of the mucosa were independently associated with ITB,with adjusted odds ratios of 8.6(95%CI:2.1-35.6)and 18.9(95%CI:3.5-102.8)respectively.Right lower abdominal quadrant pain on examination and involvement of≥3 intestinal segments were independently associated with CD with adjusted odds ratios of 10.1(95%CI:2.0-51.3)and 5.9(95%CI:1.7-20.6),respectively.CONCLUSION:Weight loss and mucosal nodularity were associated with ITB.Abdominal pain and excessive intestinal involvement were associated with CD.ITB and CD were equally common.

Clinical,radiological and molecular diagnosis correlation in serum samples from patients with osteoarticular tuberculosis

Objective:To assess the role of polymerase chain reaction(PCR)in serum sauples,in the diagnosis of osteoarticular tuberculosis(OTB)in a setting where only clinical and imaging diagnoses determine the treatment.Methods:A total of 44 consecutive serum specimens were collected from clinically suspected OTB patients,based on clinical and radiological[X-ray or magnetic resonance imagng/computecl tomography]features.They were scrcened by in-house nested PCR.In addition,a few specimens were examined by Gram stain,acid-fast bacilli stain,histand routine bacterial culture.A total of 39 specimens were collected from patients suffering from other bone diseases of nontuberculous origin and included as negative controls.Results:of the 44 clinically suspected OTB patients,in-house nested PCR was positive in 40(91%)cases;PCR was negative in 38(97%)negative controls.Sensitivity and specificity of our in—house nested PCR was 90.3%and 97.4%,respectively.The PCR report was available within 48 h.It was possible to standardize serum PCR technique and in positive cases,a good n was observed in terms of an adequate treatment response.Conclusions:Nested PCR in serum samples is a rapid,highly sensitive and specific modality for OTB detection,PCR should be performed in addition to clinical evaluation,imaging studies,acidfast bacilli staining,culture and histopathology diagnosis,if possible.

Misdiagnosis of tuberculosis and the clinical relevance of nontuberculous mycobacteria in Zambia

Objective:To determine the accuracy of TB diagnosis of TB in Zambia in the era of increasing HIV prevalence.Methods:Sputum of the clinically diagnosed TB cases was additionally subjected to liquid culture and molecular identification.This study distinguished between TB cases confirmed by positive Mycobacterium tuberculosis(M.tuberculosis) cultures and mycobacterial disease caused by non-tuberculous mycobacteria(NTM).Results:Only 49% of the 173 presumptively diagnosed TB cases was M.tuberculosis cultured,while in 13% (22) cases,a combination of M.tuberculosis and NTM was found.In 18% of the patients only NTM were cultured.In 28% ,no mycobacteria was cultivable.HIV positive status was correlated with the isolation of NTM(P【0.05).Conclusions:The diagnosis of tuberculosis based on symptoms, sputum smear and/or chest X-ray leads to significant numbers of false-positive TB cases in Zambia,most likely due to the increased prevalence of HIV.The role of NTM in tuberculosislike disease also seems relevant to the false diagnosis of TB in Zambia.

Fine needle aspiration diagnosis of isolated pancreatic tuberculosis: A case report

Tuberculosis(TB) involving the pancreas are uncommon, especially when present in immunocompetent hosts. Pancreatic TB is more frequently associated with miliary TB or widely disseminated disease. Pancreatic TB may present as cystic or solid pancreatic masses, pancreatic abscess or acute or chronic pancreatitis. Majority of the cases are diagnosed after surgical exploration for presumed pancreatic malignancy and preoperative diagnosis is quite difficult. However, improvement in imaging techniques and the resulting imageguided interventions gradually can obviate the need for more invasive diagnostic surgical procedures and expedite the planning of therapy. Herein, we report a rare case of isolated pancreatic TB which presented with pancreatic mass lesion in an immunocompetent host. Diagnosis was made by contrast enhanced computed tomography and guided fine needle aspiration of the pancreatic mass which revealed acid-fast bacillion Ziehl-Neelsen stain. The case was treated successfully with antituberculous drugs. Pancreatic tuberculosis should be considered in the differential diagnosis of a pancreatic mass when the patient is young, residing in the endemic zone of tuberculosis. Every attempt should be made to diagnose the cases to prevent unnecessary operation.