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.

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.

Extra-Pulmonary Tuberculosis: Retrospective Review of 83 Confirmed Cases, Observed in Radiology in Lomé(TOGO)

Background: Tuberculosis primarily affects lungs, but all organs may be affected. Extra-pulmonary forms of tuberculosis cause a big public health problem as it is diagnosed late. This delay in diagnosis is not only due to the delay in the examination, but also due to difficulties related to extra-pulmonary tuberculosis diagnostic. Aim: To describe the different locations of extra-pulmonary Tuberculosis and its aspects in Togo. Patients and Methods: A retrospective analysis of all extra-pulmonary tuberculosis cases diagnosed by imaging over five years (January 2010 to December 2015) was done. All the cases were confirmed either by direct examination of biological fluids or by histological analysis of biopsy and surgical samples or by culture on specific area. Data were collected from the Department of Radiology, from Microbiology Laboratory of the Pneumo-phthisiology unit and from Pathology Laboratory of Sylvanus Olympio Teaching Hospital of Lomé. Results: A total of 83 cases of extra-pulmonary Tuberculosis had been taken into account: 45 men and 38 women, with a maximum number of cases (66.3%) in the age group between 20 to 40 years old. An HIV infection was known in 51 patients (61.4%). Pulmonary damage was associated in 21 patients (25.3%). A total of 116 extra-pulmonary tuberculosis locations were recorded. Damages were pleural in 37.1% (43), ganglion in 24.1% (28), osteo-articular in 15.5% (18), abdominal in 12.9% (15), military represented 8.6% (10), a case of testicular damage, and a case of mammary tuberculosis. Conclusion: The medical scanning based on conventional radiography, ultrasonography and TDM is indispensable for the diagnosis and the care taking of extra-pulmonary tuberculosis since some locations may be confused with many other diseases and lead to misdiagnosis errors and delay the treatment.

Extra-Pulmonary Tuberculosis in the Uterine Cervix: A Case Report

Tuberculosis of the uterine cervix is grouped under genital tuberculosis. Other sites for genital tuberculosis include the Fallopian tubes and the endometrium. Genital tuberculosis and other types of tuberculosis outside the lungs are referred to as extra-pulmonary tuberculosis (EPTB). Genital tuberculosis presents with unspecific symptoms and signs;and because of this, most often, the diagnosis is made incidentally during investigations for other conditions that present with similar clinical pictures. Therefore, misdiagnosis and wrong treatment are not uncommon. We present a case of tuberculosis of the uterine cervix which was incidentally diagnosed when the patient was being investigated for cervical cancer, and successfully treated with a 6-months rifampicin regimen, 2RHZE/4HRE. Health providers have a duty to highly suspect tuberculosis of the cervix among women who present with abnormal vaginal discharge, abnormal vaginal bleeding and post-coital bleeding especially in countries where HIV and TB are endemic. If properly diagnosed and correctly treated, tuberculosis of the uterine cervix is curable.

Pulmonary and Extra-Pulmonary Tuberculosis: Epidemiological and Diagnostic Aspects at Sominé DOLO Hospital in Mopti

Despite the efforts made to fight the tuberculosis, Mycobacterium tuberculosis still remains a public health problem, particularly for low-income countries. According to the World Health Organization data, our country, Mali has detected only half of the 10,385 cases of tuberculosis expected for 2014 for a population of 17,309,000 inhabitants. The objective of this present work was to describe the different clinical aspects and the epidemiology of tuberculosis at Hospital Sominé Dolo in Mopti. We performed a retro-prospective and descriptive of tuberculosis cases diagnosed in our department of medicine between May 2016 and August 2018. A total of 96 tuberculosis cases were recorded, i.e. 4.6% and 1.0% for hospitalizations and consultations patterns, respectively. The median of age was 41 with extremes from 5 to 80 years. The age group [31 - 40 years] was the most affected with 20.8%. Men and women were affected in identical proportions, i.e. 50%. Pulmonary locations were the most frequent with 55.2%. Pleural tuberculosis was far the most frequent of the extra-pulmonary forms with 24.0% followed by the peritoneal and bone localization with 6.3% each. The majority of patients were followed on an outpatient basis, i.e. 90.6%. The disease lethality was 7.3%. Our data show that the cases of extra-pulmonary tuberculosis are in an increasing proportion and their diagnosis confirmation remains difficult in our context.

Previous Pulmonary Fibrosis in Dermatomyositis/Polymyositis: A Predictive Factor for Pulmonary and Extra-Pulmonary Tuberculosis

Objective: With scant studies in the literature, little is known about the risk factors for tuberculosis in patients with dermatomyositis/polymyositis. Therefore, the aim of the present study was to analyze the predictive factors for tuberculosis development in dermatomyositis/polymyositis. Methods: This single-center, retrospective, cohort study initially included 290 patients with dermatomyositis/polymyositis, from 2002 to 2016. Tuberculosis (pulmonary and/or extra-pulmonary) was confirmed after dermatomyositis/polymyositis diagnosis in 12 patients (4.1%) (Tuberculosis+ group). For the control group (Tuberculosis−), 24 patients without tuberculosis were arbitrarily selected in the same period and matched for age, ethnicity, gender, age at disease diagnosis, disease duration and type (dermatomyositis or polymyositis). Results: Tuberculosis occurred for a median of 16 months after dermatomyositis/polymyositis diagnosis. Clinical, laboratory and treatment features were similar in Tuberculosis+ and Tuberculosis−groups (P > 0.05). However, previous pulmonary fibrosis in dermatomyositis/polymyositis was more prevalent in the Tuberculosis+ group (41.7 vs. 8.3%;P = 0.029). Moreover, on a multivariate logistic regression model, pulmonary fibrosis was significantly associated with Tuberculosis (Odds ratio: 9.59, 95% confidence interval: 1.17 - 78.82). Tuberculosis affected 3 dermatomyositis cases for every 1 polymyositis case, with predominantly pulmonary followed by extra-pulmonary involvement (pleura, cutaneous, muscular, joint, soft tissue and hematologic). Two or more sites were affected in 41.7% of cases. Conclusions: Previous pulmonary fibrosis in dermatomyositis/polymyositis was a predictive factor associated with tuberculosis development. Further studies are needed to confirm these results.

Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction:A case report and review of literature

BACKGROUND Mycobacterium tuberculosis(TB)is the causative agent of TB,a chronic granulo-matous illness.This disease is prevalent in low-income countries,posing a significant global health challenge.Gastrointestinal TB is one of the three forms.The disease can mimic other intra-abdominal conditions,leading to delayed diagnosis owing to the absence of specific symptoms.While gastric outlet obs-truction(GOO)remains a frequent complication,its incidence has declined with the advent of proton pump inhibitors and Helicobacter pylori eradication therapy.Gastroduodenal TB can cause upper gastrointestinal hemorrhage,obstruction,and malignancy-like tumors.CASE SUMMARY A 23-year-old male presented with recurrent epigastric pain,distension,nausea,vomiting,and weight loss,prompting a referral to a gastroenterologist clinic.Endoscopic examination revealed distorted gastric mucosa and signs of chronic inflammation.However,treatment was interrupted,possibly owing to vomiting or comorbidities such as human immunodeficiency virus infection or diabetes.Subsequent surgical intervention revealed a dilated stomach and diffuse thickening of the duodenal wall.Resection revealed gastric wall effacement with TB.CONCLUSION Primary gastric TB is rare,frequently leading to GOO.Given its rarity,suspicions should be promptly raised when encountering relevant symptoms,often requiring surgical intervention for diagnosis and treatment.

Push forward LC-MS-based therapeutic drug monitoring and pharmacometabolomics for anti-tuberculosis precision dosing and comprehensive clinical management

The spread of tuberculosis(TB),especially multidrug-resistant TB and extensively drug-resistant TB,has strongly motivated the research and development of new anti-TB drugs.New strategies to facilitate drug combinations,including pharmacokinetics-guided dose optimization and toxicology studies of first-and second-line anti-TB drugs have also been introduced and recommended.Liquid chromatography-mass spectrometry(LC-MS)has arguably become the gold standard in the analysis of both endo-and exo-genous compounds.This technique has been applied successfully not only for therapeutic drug monitoring(TDM)but also for pharmacometabolomics analysis.TDM improves the effectiveness of treatment,reduces adverse drug reactions,and the likelihood of drug resistance development in TB patients by determining dosage regimens that produce concentrations within the therapeutic target window.Based on TDM,the dose would be optimized individually to achieve favorable outcomes.Pharmacometabolomics is essential in generating and validating hypotheses regarding the metabolism of anti-TB drugs,aiding in the discovery of potential biomarkers for TB diagnostics,treatment monitoring,and outcome evaluation.This article highlighted the current progresses in TDM of anti-TB drugs based on LC-MS bioassay in the last two decades.Besides,we discussed the advantages and disadvantages of this technique in practical use.The pressing need for non-invasive sampling approaches and stability studies of anti-TB drugs was highlighted.Lastly,we provided perspectives on the prospects of combining LC-MS-based TDM and pharmacometabolomics with other advanced strategies(pharmacometrics,drug and vaccine developments,machine learning/artificial intelligence,among others)to encapsulate in an all-inclusive approach to improve treatment outcomes of TB patients.

Analysis of the influencing factors and clinical related characteristics of pulmonary tuberculosis in patients with type 2 diabetes mellitus

BACKGROUND In China,the prevalence of type 2 diabetes mellitus(T2DM)among diabetic patients is estimated to be between 90%-95%.Additionally,China is among the 22 countries burdened by a high number of tuberculosis cases,with approximately 4.5 million individuals affected by active tuberculosis.Notably,T2DM poses a significant risk factor for the development of tuberculosis,as evidenced by the increased incidence of T2DM coexisting with pulmonary tuberculosis(T2DMPTB),which has risen from 19.3%to 24.1%.It is evident that these two diseases are intricately interconnected and mutually reinforcing in nature.AIM To elucidate the clinical features of individuals diagnosed with both T2DM and tuberculosis(T2DM-PTB),as well as to investigate the potential risk factors associated with active tuberculosis in patients with T2DM.METHODS T2DM-PTB patients who visited our hospital between January 2020 and January 2023 were selected as the observation group,Simple DM patients presenting to our hospital in the same period were the control group,Controls and case groups were matched 1:2 according to the principle of the same sex,age difference(±3)years and disease duration difference(±5)years,patients were investigated for general demographic characteristics,diabetes-related characteristics,body immune status,lifestyle and behavioral habits,univariate and multivariate analysis of the data using conditional logistic regression,calculate the odds ratio(OR)values and 95%CI of OR values.RESULTS A total of 315 study subjects were included in this study,including 105 subjects in the observation group and 210 subjects in the control group.Comparison of the results of both anthropometric and biochemical measures showed that the constitution index,systolic blood pressure,diastolic blood pressure and lymphocyte count were significantly lower in the case group,while fasting blood glucose and high-density lipoprotein cholesterol levels were significantly higher than those in the control group.The results of univariate analysis showed that poor glucose control,hypoproteinemia,lymphopenia,TB contact history,high infection,smoking and alcohol consumption were positively associated with PTB in T2DM patients;married,history of hypertension,treatment of oral hypoglycemic drugs plus insulin,overweight,obesity and regular exercise were negatively associated with PTB in T2DM patients.Results of multivariate stepwise regression analysis found lymphopenia(OR=17.75,95%CI:3.40-92.74),smoking(OR=12.25,95%CI:2.53-59.37),history of TB contact(OR=6.56,95%CI:1.23-35.03)and poor glycemic control(OR=3.37,95%CI:1.11-10.25)was associated with an increased risk of developing PTB in patients with T2DM,While being overweight(OR=0.23,95%CI:0.08-0.72)and obesity(OR=0.11,95%CI:0.02-0.72)was associated with a reduced risk of developing PTB in patients with T2DM.CONCLUSION T2DM-PTB patients are prone to worse glycemic control,higher infection frequency,and a higher proportion of people smoking,drinking alcohol,and lack of exercise.Lymphopenia,smoking,history of TB exposure,poor glycemic control were independent risk factors for T2DM-PTB,and overweight and obesity were associated with reduced risk of concurrent PTB in patients with T2DM.

Treatment of primary nasal tuberculosis with anti-tumor necrosis factor immunotherapy:A case report

BACKGROUND Primary nasal tuberculosis(TB)is a rare form of extrapulmonary TB,particularly in patients receiving anti-tumor necrosis factor(TNF)immunotherapy.As a result,its diagnosis remains challenging.CASE SUMMARY A 58-year-old male patient presented to the ear,nose,and throat department with right-sided nasal obstruction and bloody discharge for 1 month.He was diagnosed with psoriatic arthritis and received anti-TNF immunotherapy for 3 years prior to presentation.Biopsy findings revealed chronic granulomatous inammation and a few acid-fast bacilli,suggestive of primary nasal TB.He was referred to our TB management department for treatment with oral anti-TB agents.After 9 months,the nasal lesions had disappeared.No recurrence was noted during follow-up.CONCLUSION The diagnosis of primary nasal TB should be considered in patients receiving TNF antagonists who exhibit thickening and crusting of the nasal septum mucosa or inferior turbinate,particularly when pathological findings suggest granulomatous inflammation.

Interferon-gamma release assays as a tool for differential diagnosis of gastrointestinal tuberculosis

In this editorial,we comment on an article published in a recent issue of the World Journal of Clinical Cases.There is a pressing need for reliable tools for diagnosing tuberculosis(TB)of the gastrointestinal tract.Despite advancements in the diagnosis and treatment,TB remains a global health challenge.Ali et al demon-strated that TB may mimic gastrointestinal conditions,such as gastric outlet obstruction,causing a delay in the diagnosis.Furthermore,the latter complication is frequently observed during infections,including Helicobacter pylori,and rarely is related to TB,as in the presented case.In line with this,we think that laboratory tests based on interferon-gamma release assays can be a helpful tool for diagnosing latent TB paced in the gastrointestinal tract.Innovative strategies and approaches for diagnosing latent/active extra pulmonary TB are crucial for establishing the diagnosis early and enhancing treatment strategies to mitigate the global burden of TB.

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.

Influence of Temperature and Humidity on the Incidence of Pulmonary Tuberculosis in Hainan,China,2004-2018

According to the World Health Organization’s Global Tuberculosis Report 2023,there were 10.6 million cases of tuberculosis(TB)worldwide in 2022,an increase of 2.8%over 2021,and 1.3 million people had already died of the disease.The report also indicated that approximately 748,000 new cases occurred in China in 2022,accounting for 7.1%of the global total,with an incidence of 52/100,000.

psk1 virulence gene-induced pulmonary and systemic tuberculosis in a young woman with normal immune function:A case report

BACKGROUND Tuberculosis is a chronic infectious disease and an important public health pro-blem.Despite progress in controlling tuberculosis,the incidence of tuberculosis in China is still very high,with 895000 new cases annually.This case report des-cribes the investigation of a case of severe disseminated tuberculosis in a young adult with normal immune function,conducted to ascertain why a Mycobacterium tuberculosis(M.tuberculosis)strain caused such severe disease.CASE SUMMARY A previously healthy 28-year-old woman presented to our hospital with a 1-mo-nth history of fever and fatigue.She was diagnosed with severe disseminated pulmonary tuberculosis,spinal tuberculosis with paravertebral abscesses,and tuberculous meningitis.M.tuberculosis was isolated from bronchoal-veolar lavage fluid.She was treated with standard antituberculous therapy and underwent debridement,bone graft,and internal fixation surgery for spinal tuberculosis.She responded to therapy and regained her ability to walk following the surgery.We analysed the whole-genome sequence of the strain and designated it BLM-A21.Additional M.tuberculosis genomes were selected from the Virulence Factor Database(http://www.mgc.ac.cn/cgi-bin/VFs/genus.cgi?Genus=Mycobacterium)for comparison.An evolutionary tree of the BLM-A21 strain was built using PhyML maximum likelihood software.Further gene analysis revealed that,except for the pks1 gene,BLM-A21 had similar virulence genes to the CDC 1551 and H37Rv strains,which have lower dissemination.CONCLUSION We speculate that the pks1 virulence gene in BLM-A21 may be the key virulence gene responsible for the wide-spread dissemination of M.tuberculosis infection in this previously healthy adult with normal immune function.

Revisiting tuberculosis as a cause of gastric outlet obstruction:Insights from a case report

Gastroduodenal tuberculosis(GD-TB)is exceptionally rare.The clinical manifestations of gastrointestinal TB are diverse and non-specific,which makes diagnosis difficult,leading to delayed diagnosis and high mortality.As a peer-reviewer of World Journal of Clinical Cases,I would like to share my opinion on the article published by this journal.The patient had no family history of TB or contact with people with TB.Primary GD-TB presenting as gastric outlet obstruction and normal findings of thoracic computed tomography increased the difficulty of diagnosis and treatment in this patient.The diagnosis and treatment scheme of this typical case have reference value for the clinical treatment of GD-TB.

COVID-19/Tuberculosis Co-Infection at the Epidemic Treatment Center (ETC) of Saint-Louis (Senegal): About 9 Cases

Introduction: COVID-19 is a global public health emergency that can cause acute respiratory distress syndrome. In countries where tuberculosis (TB) is endemic, coinfection of COVID-19 and TB is often encountered, which increases the risk of developing severe forms of COVID-19. Objectives: The aim of this study was to determine the prevalence of COVID-19/TB coinfection at the Epidemic treatment center (ETC) in Saint-Louis (Senegal) and to describe the epidemiological, clinical, paraclinical, and outcome profile of co-infected patients. Patients and Methods: This is a retrospective, cross-sectional, descriptive cohort study based on the records of COVID-19/ TB co-infected patients who were hospitalized at the ETC in Saint-Louis (Senegal) over an 18-month period from March 2020 to September 2021. Results: Out of a total of 454 hospitalizations, we collected records of 9 patients co-infected with COVID-19/TB, resulting in a prevalence of 2%. The study included patients with a median age of 34 years (range: 10-86 years), with a male predominance (7 cases) and a sex ratio of 3.5. The majority of patients (88.9%) had severe forms of COVID-19. Dyspnea and cough were reported in all patients (100%). Pulmonary TB was the most frequent localization, with 9 cases. The diagnosis of COVID-19 was confirmed by nasopharyngeal PCR in all patients (100%). Bacilloscopy was positive in 3 out of 5 cases. One patient tested positive for GeneXpert? MTB/RIF without rifampicin resistance. All patients were prescribed the hydroxychloroquine-azithromycin combination and anti-tuberculosis treatment. Out of the nine patients, four recovered (44.4%) and five died (55.5%). Conclusion: COVID-19/TB coinfection had a low prevalence in our cohort, but was associated with a high mortality due to the frequent occurrence of severe forms of the disease.

Recognizing and addressing the challenges of gastrointestinal tuberculosis

In this editorial,we comment on the article by Ali et al published in the recent issue of the World Journal of Clinical Cases.This case report shed light on a particularly rare manifestation of this disease-primary gastrointestinal tuberculosis(GTB)presenting as gastric outlet obstruction.GTB presents diagnostic challenges due to its nonspecific symptoms and lack of highly accurate diagnostic algorithms.This editorial synthesizes epidemiological data,risk factors,pathogenesis,clinical presentations,diagnostic methods,and therapies to raise awareness about GTB.GTB constitutes 1%-3%of all tuberculosis cases globally,with 6%-38%of patients also having pulmonary tuberculosis.Pathogenesis involves various modes of Mycobacterium tuberculosis complex entry into the gastrointestinal system,with the terminal ileum and ileocecal valve commonly affected.Clinical presentation varies,often resembling other intra-abdominal pathologies,necessitating a high index of suspicion.Diagnostic tools include a combination of biochemical,microbiological,radiological,and endoscopic assessments.Antitubercular medication remains the cornerstone of treatment,supplemented by surgical intervention in severe cases.Multidisciplinary management involving gastroenterologists,surgeons,pulmonologists,and infectious disease specialists is crucial for optimal outcomes.Despite advancements,timely diagnosis and management challenges persist,underscoring the need for continued research and collaboration in addressing primary GTB.

What Mice Can Teach Us about How to Stop Drug-Resistant Tuberculosis:Correct Chemotherapy Regimen and Patient Compliance are the Key

Despite well-known limitations,mice remain useful as model animals to study tuberculosis(TB)pathogenesis,the basic immune response,the extent of lung pathology as well as efficacy of new drugs against Mycobacterium tuberculosis[1,2].There are four routes of tuberculosis infection in mice:aerosol generation and exposition,intravenous injection,intranasal administration,and subcutaneous administration[3].

BPaL/BpaLM regimen:A bright future for drug-resistant tuberculosis

Indonesia is one of the countries with the highest burden of tuberculosis and drug-resistant tuberculosis(DR-TB)across the world.Based on data from the World Health Organization(WHO)Global TB Report 2023,it is estimated that there are 10000 cases of DR-TB in Indonesia.Bedaquiline,a novel antitubercular drug,has been implemented to treat DR-TB globally.It was administered either a shorter(9 months)or individualized treatment regimen(18 months).However,long treatment duration with various adverse events affects patient compliance.Therefore,a short treatment with less medication is urgently required.In 2022,the WHO announced an alternative regimen-bedaquiline,pretomanid,linezolid,and moxifloxacin(BPaLM)to treat DR-TB patients for six months without resistance to fluoroquinolones[1].This recommendation is based on previous clinical trials of TB,Zenix TB,and TB-PRACTECAL.The introduction of BPaL and BPaLM provided a bright future for treating DR-TB patients.

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.