Sputum Acid-fast Bacilli Research Articles

Fluorescein Diacetate Vital Staining for Detecting Viability of Acid-Fast Bacilli in Sputum of Pulmonary Tuberculosis Patients

Fluorescein Diacetate Vital Staining for Detecting Viability of Acid-Fast Bacilli in Sputum of Pulmonary Tuberculosis Patients

Pattern of Childhood Tuberculosis in the Outpatient Department of a Tertiary Level Hospital in Dhaka City

Introduction: Tuberculosis (TB) in children is increasingly becoming an important cause of global child morbidity and mortality. Objective: The objective of this study was to evaluate the clinical spectrum of TB in children under the age of 15 years and document any changes that occur over time. Materials & Methods: This observational study was conducted in the pediatric outpatient department (OPD) of 250 Bedded TB Hospital, Shyamoli, Dhaka, from October’2016 to January’2017. A total 71 children of both sex up to 15 years of age, who were diagnosed as having TB and attended the pediatric OPD of TB hospital during the four months study period were enrolled. The data was analyzed on the basis of patient’s age, gender, socioeconomic status, mode of presentation, BCG vaccination status, history of contact with smear positive TB patient, clinical findings, investigations and associated co-morbidities. Results: This study revealed that among the 71 cases of TB, (72%) had extra-pulmonary TB (EPTB) and (28%) had pulmonary TB (PTB), the commonest age group was 6 to 15 years with male preponderance (51%). Pulmonary TB was diagnosed mostly clinically (60%) followed by positive sputum smear result (20%), gastric aspirate for acid-fast bacilli AFB (5%) and sputum for Gene Xpert (5%). Distribution of extra-pulmonary TB (EPTB) according to the organ involvement was TB lymphadenitis (49%), osteoarticular TB (19.6%) and abdominal TB (5.9%). Cervical lymphadenopathy was the commonest presentation (76%) among the EPTB cases. Tuberculin skin test (TST) was positive in (69%) cases. Among the total cases (90%) children had TB alone whereas (10%) had other co-morbid disease along with TB. Conclusion: Extra-pulmonary TB (EPTB) was more prevalent among the childhood TB cases in a tertiary level set up where cervical TB lymphadenitis was the commonest.

The Prevalence of Absolute and Functional Iron Deficiency Anemia in New Cases of Smear-positive Pulmonary Tuberculosis and Their Sputum Conversion Rate at the End of Intensive Tuberculosis Treatment Phase.

About one third of the population is infected with tuberculosis (TB). On the other hand, iron deficiency is the most common micronutrient deficiency in the world. A number of studies have documented anemia in patients with TB, however, this study aimed to assess the prevalence of iron deficiency anemia (IDA) in patients with acid-fast bacilli (AFB) sputum smear-positive, and sputum conversion in these two groups of patients with absolute and functional IDA at the end of the second month of anti-TB therapy in Zahedan, Iran. The results of this study revealed that 91 out of 198 (45.9%) sputum positive pulmonary TB patients were anemic, and among those 72 (79.1%) had iron deficiency anemia. The overall prevalence of IDA in this study was 36.3%. In 72 patients with IDA, 54 (75%) had functional while the remainder had absolute IDA 18 (25%). Twenty-one out of 72 (29.2%) of patients with IDA remained sputum positive and among 126 non IDA patients 47 (37.3%) had positive sputum smear at the end of intensive TB treatment phase (p=0.278). Approximately, less than half of patients with tuberculosis had anemia among them 79% had iron deficiency anemia. The frequency of functional IDA was three times more than absolute IDA. There was no statistically significant difference in sputum conversion between two groups of IDA and non-IDA patients after intensive phase of anti-TB therapy.

Nontuberculous mycobacterial pulmonary disease in a 16-year-old female patient with bronchiectasis

Nontuberculous mycobacterial (NTM) pulmonary disease generally occurs in old people with underlying lung disease. However, unlike adults, NTM infections in children with normal immunity are rare, and they occasionally manifest as lymphadenitis. We herein present a rare case of NTM pulmonary disease in a girl who is the youngest patient reported in Korea. A 16-year-old female was brought to the hospital because of dyspnea on exertion, fever, and productive cough. The patient had bronchiectasis. She under went Fontan operation for right isomerism, double outlet right ventricle, pulmonary stenosis, and had been taking prophylactic an tibiotics for asplenia. NTM were found in the sputum and bronchoalveolar lavage fluid by acid fast bacillus (AFB) staining and cul ture, which were identified as Mycobacterium avium. The treatment started with azithromycin, ethambutol and rifampicin. After 6 months of treatment, respiratory symptoms improved and the sputum AFB culture became negative. She is currently on medica tion with above-mentioned drugs for 10 months without any adverse effects. This case suggests that NTM pulmonary disease should be suspected and properly treated especially in children and adolescents with underlying lung disease. (Allergy Asthma Respir Dis 2020;8:231-236)

Atypical cause of fever in advanced pregnancy

Although miliary tuberculosis (TB) is uncommon in pregnancy, it is difficult to diagnose when present and is often associated with a maternal history of intravenous drug abuse, malignancy, alcoholism, or human immunodeficiency virus (HIV) infection. TB in pregnancy can present with non-pulmonary symptoms, making the diagnosis and treatment challenging. We report a case of military TB in a lady with advanced pregnancy who presented with fever and cough without any history of exposure to TB patient. There was no history of alcoholism, intravenous drug abuse, or any other risk factors. Sputum for acid-fast bacilli stains and HIV screening were negative. The patient was started on anti-TB treatment after blood investigations ruled out other causes of fever and chest radiograph was suggestive of miliary TB. Confirming the diagnosis of miliary TB is an arduous process requiring a high index of suspicion. During pregnancy, histopathologic examination of tissue biopsy and GeneXpert may facilitate making an early diagnosis of extrapulmonary TB.

Use of sodium dodecyl sulfate to improve tuberculosis sputum smear microscopy.

Sputum smear microscopy (SSM), the most widely available tool for tuberculosis (TB) detection, has limited performance in paucibacillary patients and requires highly experienced technicians. The objective of this study was to determine whether the addition of sodium dodecyl sulfate (SDS), a detergent that thins sputum, at 4% and 10%, improves the detection of acid-fast bacilli (AFB), the clarity of slides, and the biosafety of the technique. Thirty participants with presumptive TB were enrolled. Three independent, blinded technicians examined the slides. Regular sputum concentrated AFB smear and sputum culture were used as standard control methods. Sputum culture was also performed before and after 10% SDS addition for safety analysis. We found that neither SSM with SDS 4% nor SSM with SDS 10% improved the test’s performance. However, slides with 4% and 10% SDS, compared with slides prepared without SDS, had significantly better clarity scores. The 10% SDS-prepared sputum samples were all culture negative. While adding SDS detergent does not improve the performance of SSM slides, it does improve the clarity and biosafety. Where experienced technicians are scarce, especially in low resource settings, use of SDS may enhance the ease of slide reading in sputum smear microscopy.

Rifampicin Induced Hyperbilirubinemias: A Case Report.

Abstract Anti-tubercular therapy (ATT) induced hepatitis is a major problem which a physician encounters in his clinical practice. A case of 28-year old female, weighing 45 kg was brought to hospital with the chief complains of low-grade fever for the past two months, cough, shortness of breath and 4-5 kg weight loss in two months. She had no history of hypertension (HTN), diabetes mellitus (DM), pulmonary tuberculosis (PTB). Her Chest X-ray showed right sided bilateral pulmonary TB and sputum acid fast bacilli (AFB) smear was repeatedly positive. Pulmonologist has started Category-I anti-tubercular regimen (Rifampicin, Isoniazid, Pyrazinamide and Ethambutol) under DOTS as per RNTCP guidelines. After 7 days of starting the treatment (DOTS regimen), she noticed yellowish discoloration of sclera, orange discoloration of urine but in spite of this she continued the drug for a further two weeks. Patient was found to be developing hepatotoxicity with the findings of elevated total bilirubin (10.2 mg/dl), conjugated bilirubin (2.5 mg/dl) and unconjugated bilirubin (7.2 mg/dl). Viral markers for hepatitis including hepatitis B viruses (HBsAg), hepatitis C viruses (HCV), human immunodeficiency virus (HIV), were all are non-reactive. Pulmonologist made provisional diagnosis of anti-tubercular drugs (specially rifampicin) induced hyperbilirubinemias. Pulmonologist initially hold Rifampicin and Pyrazinamide, but started Isoniazid, Ethambutol, Ofloxacin, Pyridoxine along with liver enzyme. She showed gradual improvement as bilirubin after one-week had dropped down to 1.2 mg/dl. Rifampicin was added to the regimen and the serum bilirubin checked after 1 week was found 1 mg/dl. Pyrazinamide was added after repeated LFTs showed normal values. Patient continued her drugs and came for review after three months. She was advised to continue and complete the course of anti-tubercular drugs. Since Rifampicin is the most important first line anti-tubercular drug it is very important to restart this drug in order to have a satisfactory response to anti-tubercular therapy. We have reported this case because of its rarity in clinical practice. As a health care team member clinical pharmacist are need to be made aware of these potentially fatal adverse effects associated with anti-tubercular therapy via conduction of quality-based seminars, published medical literature, conferences, learning programs and health care camps.

1362. A Case Series of Miliary Tuberculosis in North West London

BackgroundMiliary tuberculosis (mTB) is a severe presentation of TB with high mortality. We reviewed data from a cohort of patients with mTB in an area of London serving an ethnically diverse population with the highest TB endemicity in the UK.MethodsRetrospective analysis of laboratory and medical records, radiology and microbiology results of patients with mTB identified from the London TB register from 2012 to 2019 from London North West Hospitals University NHS Trust.Results60 cases with mTB were recorded. 67% of the patients were male. Median age at diagnosis was 36 years (range 13 to 88 years). 60% of patients were South Asian ethnicity. Two patients were HIV positive and 4 had received anti-TNF treatment. 73% (44 patients) patients had miliary nodular opacities on chest radiograph. Of the 16 patients with no chest radiograph evidence of mTB, 14 had computed tomography (CT) of the chest which confirmed miliary nodules. Eleven patients were sputum acid-fast bacilli (AFB) smear-positive, and in 49 patients, culture of sputum isolated Mycobacterium tuberculosis. Ten patients did not have any positive microbiology but were treated for mTB on clinico-radiological basis. Forty patients had fully-sensitive TB; 2 were isoniazid-resistant and 1 multi-drug-resistant. 5 patients in our cohort also had spinal TB. Evidence of cerebral TB was found in 5/17 patients who had a CT brain. Tuberculomas were seen in 10/24 patients who had magnetic resonance imaging (MRI). Only 8 patients had both CT and MRI; MRI revealed2 patients with cerebral TB that CT did not, but this was not statistically significant (P = 0.1573). 7 patients were investigated with lumbar puncture, of which cerebrospinal fluid was smear and culture negative for all. All patients were treated with standard therapy with a mean length of treatment of 11 months. 33 patients have completed therapy. 7 patients died and 2 were lost to follow-up. Those who died had a mean age of 69 years compared with those who survived (44.2 years).ConclusionThe diagnosis of mTB requires a high index of suspicion for central nervous system disease. Our cohort demonstrates that spinal disease needs to be considered in addition to cerebral TB, for which MRI may be the preferred imaging modality. Mortality in our cohort was associated with older age.Disclosures All authors: No reported disclosures.

1379. Comparison of Inpatient Tuberculosis Screening Methods and Their Effect on Patient Duration in Airborne Isolation

BackgroundTuberculosis (TB) remains a significant public health concern, and exposure in healthcare settings is prevalent. Current guidelines recommend testing for TB by acid-fast bacilli (AFB) smear microscopy with 3 sputum samples and/or using nucleic acid amplification test (NAAT), and mycobacterium culture. The purpose of this project is to compare how different TB diagnostic tests affect the duration of stay in respiratory isolation.MethodsThis study was conducted at the Veteran Affairs South Texas hospital, which includes a total of 437 beds. Data were collected retrospectively from medical records. Eligibility included patients admitted to the hospital and placed in airborne isolation for TB screening and diagnosis, had 3 sputum samples collected 8 hours apart and/or had 2 PCR MTB/RIF. Patients were excluded if they had TB or were not undergoing evaluation for TB. Three time periods analyzed included, 3 AFB sputum samples analyzed in-house from December 2012 to January 2014 (Group A), 3 AFB sputum samples analyzed at outside facility during 2013 to 2014 as well as 2 months in 2012 (Group B), and 2 MTB PCR/RIF in house during 2017 and 2018 (Group C). Duration of isolation was compared between groups using the Kruskal–Wallis test. A total number of 815 patients were screened, leaving 105 patients for analysis after exclusion. There were 49 patients analyzed from Group A, 28 from Group B, and 28 from Group C.ResultsCrude analysis of the data showed numerical differences in the total number of days and hours in isolation between the 3 groups. The average (mean) days in isolation were 4.2 for Group A, 7.4 for Group B, and 5.5 for Group C. There was no statistically significant difference in either days or hours of airborne precautions by “rule out” method. Days of isolation in airborne precautions (median IQR) was 4 for all groups (P = 0.3313). Likewise, hours of airborne precautions had a median IQR of 96 for all groups P = 0.4347.ConclusionAlthough there was no statistical significance between the groups, crude analysis did show a numerical difference in the mean total airborne days and hours. Lack of statistical difference may be due to low number of patients, timing of order placement for in-house PCR, and longer than expected stay in airborne precautions.Disclosures All authors: No reported disclosures.

Population-based screening for pulmonary tuberculosis utilizing community health workers in Ethiopia

ObjectiveTo evaluate the utility of a volunteer health development army in conducting population screening for active tuberculosis (TB) in a rural community in southern Ethiopia. MethodsA population-based cross-sectional survey was conducted in six kebeles (the lowest administrative units). Volunteer women community workers led a symptom screening programme to identify adults ≥15 years of age with TB in the community. Individuals with a cough for ≥2 weeks had spot and morning sputum samples taken, which were examined using acid-fast bacillus (AFB) smear microscopy, culture, and Xpert MTB/RIF. ResultsAll 24517 adults in the study area had a symptom screen performed; 544 (2.2%) had had a cough for ≥2 weeks. Among those with a positive symptom screen, 13 (2.4%) were positive on sputum AFB smear microscopy, 13 (2.4%) had a positive culture, and 32 (5.8%) had a positive Xpert MTB/RIF test. Overall, 34 TB cases (6%) were identified by culture and/or Xpert, corresponding to a prevalence of 139 per 100000 persons. ConclusionsThis study demonstrated the capability of community health workers (volunteer and paid) to rapidly conduct a large-scale population TB screening evaluation and highlight the high yield of such a programme in detecting previously undiagnosed cases when combined with Xpert MTB/RIF testing. This could be a model to implement in other similar settings.

Clinical and Demographic Characteristics Differences between M. tuberculosis and M. bovis Infection in Bronchoalveolar Lavage Pulmonary TB Patients, Indonesia

Background: Some species of the Mycobacterium tuberculosis complex (MTBC) which can cause tuberculosis, particularly M. tuberculosis and M. bovis, may have different virulence property and therefore associated with various clinical severity in tuberculosis (TB) patients. The aim of this study was to determine the differences in clinical and demographic characteristics between M. tuberculosis and M. bovis infection among Indonesian TB patients.
 Methods: Thirty-one new and active TB patients were confirmed to have acid fast bacilli (AFB) sputum positive and/or Xpert MTB/RIF positive for M. tuberculosis from Dr. Soewandhie Hospital, Surabaya, Indonesia. Interviews were conducted to record the clinical and demographics required. The MTBC were isolated from bronchoalveolar lavage fluid (BALF) and determined by primer-specific PCR targeting TbD1 and RD9 region gene. The degree of lung tissue damage was classified using NICE Scoring System. 
 Results: The MTBC were detected in all patients on whom 19 and 12 isolates were classified as M. tuberculosis and M. bovis respectively. There was a different on 74.2% of productive age subjects (21-50 years) with M. tuberculosis infection (P

Cannonball opacities in a pregnant woman.

A 26-year-old woman presented at week 20 of pregnancy with a 3-month history of fever, cough, and breathlessness. She had hearing loss, epistaxis, nasal crusting, haemoptysis, and a purpuric rash over her legs. No significant weight loss was reported. Chest x-ray (with abdominal shield) showed bilateral cannonball opacities, and contrast-enhanced chest CT (with abdominal shield) revealed multiple nodules, without pleural effusion or lymphadenopathy (figure). Ultrasound of the patient's abdomen and pelvis showed a single live fetus and no abnormalities. Her haemoglobin concentration was 8·3 g/dL, total leucocyte count was 8·6 × 109/L, platelet count was 600 × 109/L, erythrocyte sedimentation rate was 65 mm/h, and C-reactive protein concentration was 186 mg/L. The patient's serum anti-proteinase 3 antibody concentration was 102 U/mL. Sputum acid-fast bacilli and fungal smear, serum β-D-glucan and galactomannan, and Mantoux test results were all negative. A diagnosis of granulomatosis with polyangiitis was made.

A CASE OF ISOLATED TB PLEURAL EFFUSION

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pleural tuberculosis accounts as one of the most common extrapulmonary manifestations of tuberculosis, second only to lymphadenopathy. Tuberculous pleural effusion (TPE) is the most common form of exudative effusion in the developing world. Isolated pleural involvement without parenchymal involvement is unusual. We report a patient with a lymphocytic exudative effusion that was revealed to be TPE only upon result of pleural acid-fast bacilli (AFB) culture, with the sputum and pleural AFB smears and pleural adenosine deaminase (ADA) being nondiagnostic. CASE PRESENTATION: A 64 year old Filipino male presented to the hospital with fever, chills, night sweats, and epigastric pain for 1 week. He was found to have a right pleural effusion with thickened pleural lining suspicious for empyema, measuring 8.8cm x 2.0cm x 8.2cm. He was placed in airborne precautions to rule out tuberculosis. A thoracentesis was performed that revealed a lymphocytic predominant (880 cells, 97% lymphocytes, 1% neutrophils) effusion. No organisms were seen on gram stain, bacterial culture, or AFB smear. Pleural fluid adenosine deaminase level was 37 U/L. After three induced sputum AFB smears resulted as negative, he was discharged at which point his symptoms had resolved. Patient was later seen in clinic a month after discharge at which point he was still asymptomatic. However, his pleural AFB cultures grew Mycobacterium tuberculosis, and he was started on anti-tuberculous therapy with rifampin, isoniazid, ethambutol, and pyrazinamide. DISCUSSION: This case resulted in a diagnosis of tuberculous pleural effusion despite the absence of pulmonary tuberculosis disease. Guidelines for the diagnosis of suspected pleural tuberculosis recommend the measurement of pleural ADA. Proposed pleural ADA cutoff values range from 10 U/L to 71U/L, with most studies using a level <40 U/L as the cutoff to exclude the diagnosis of TPE. Despite the highly lymphocytic predominant effusion, our patient's pleural fluid ADA level of 37 U/L led to a false reassurance of a non-tuberculosis diagnosis and a delay in diagnosis and treatment. In retrospect, a higher index of suspicion for TPE should have been maintained in this patient who presented with such a constellation of symptoms and radiographic evidence of an inflammatory effusion coupled with a suspicious pleural fluid analysis. Further diagnostics that could have been pursued to improve diagnostic sensitivity include needle biopsy or thoracoscopic pleural biopsy. Reference #1: Ciaran F. Keogh, Gordon T. Andrews, Sian D. Spacey, Kevin E. Forkheim, and Douglas A. Graeb. Neuroimaging Features of Heroin Inhalation Toxicity: “Chasing the Dragon” American Journal of Roentgenology 2003 180:3, 847-850 Reference #2: Blasel S, Hattingen E, Adelmann M, Nichtweiss M, Zanella F, Weidauer S. Toxic leukoencephalopathy after heroin abuse without heroin vapor inhalation: MR imaging and clinical features in three patients. Clin Neuroradiol. 2010;20(1):48-53. Reference #3: In Sub Yoo, MD, Sang Hak Lee, MD, Seung-Han Suk, MD, PhD. A Case of Fentanyl Intoxication and Delayed Hypoxic Leukoencephalopathy Caused by Incidental Use of Fentanyl Patch in a Healthy Elderly Man. J Neurocrit Care. 2015;8 (1):35-38. DISCLOSURES: No relevant relationships by Jasanjeet Jawanda, source=Web Response No relevant relationships by Antarpreet Kaur, source=Web Response No relevant relationships by Abhas Khurana, source=Web Response No relevant relationships by Simrina Sabharwal, source=Web Response

NECROTIZING CAVITARY LUNG MASS IN PATIENT WITH AIDS: A RARE MANIFESTATION OF PNEUMOCYSTIS JIROVECII PNEUMONIA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pulmonary infections in immunocompromised hosts encompass a wide differential diagnosis. Of the possible etiologies, Pneumocystis jirovecii presents as a rare cause of necrotizing cavitary pneumonia, particularly in patients with advanced HIV and AIDS. CASE PRESENTATION: A 50-year-old male patient presented with progressively worsening cough productive of green blood-tinged sputum of 2-week duration, associated with pleuritic chest pain, night sweats, and diarrhea. Past medical history was significant for AIDS due to HIV-1 with CD-4 count 73/mm3 not on antiretroviral therapy. He was admitted to an outside hospital two months prior for similar symptoms, and chest x-ray at that time demonstrated no acute process (figure 1A). On presentation he was tachycardic, tachypneic, and afebrile. Oxygen saturation was 98-100% on room air. Physical examination revealed inspiratory crackles on right upper lung field auscultation with associated dullness to percussion, tenderness in the epigastrium and right upper quadrant of the abdomen, and oral thrush. CXR demonstrated diffuse airspace opacification throughout the right upper lobe (RUL), with internal lucent areas consistent with cavitation (figure 1B). A follow-up chest computed tomography (CT) with intravenous contrast demonstrated cavitation of the RUL, with cystic spaces and air fluid levels (figure 2,3). Sputum culture was grossly contaminated with oropharyngeal flora. Three consecutive acid-fast bacilli (AFB) sputum smears were initially negative. Pneumocystis qualitative PCR was positive, with B-D glucan assay (Fungitell) of 239 pg/mL (ref range: <60 pg/mL). Histoplasma urine antigen was negative. Cryptococcus serum testing was negative. A bronchoscopy with bronchoalveolar lavage (BAL) demonstrated findings consistent with necrotizing cavitary pneumonia. Pneumocystis was again identified on qualitative PCR. Anaerobic and aerobic culture, AFB culture, Nocardia, Legionella, and fungal culture were negative. No malignant cells were visualized. After 4 weeks of incubation, the AFB culture from sputum sampling on admission demonstrated Mycobacterium avium complex (MAC) growth in 1 of 3 samples consistent with contamination. DISCUSSION: This case highlights the complexity of cavitary pulmonary lesion diagnosis in an patient with AIDS. The diagnosis of Pneumocystis pneumonia (PCP) was made through sputum and BAL qualitative PCR testing, with fungitell assay testing. The atypical radiographic presentation necessitated exclusion of alternate diagnoses. The possibility of superimposed anaerobic infection was not entirely ruled out, however the location of cavitation with multiple negative cultures on sputum and BAL sampling made this less likely. CONCLUSIONS: Pneumocystis jirovecii can present as a necrotizing cavitary pneumonia, and increased awareness regarding this atypical and rare presentation is critical for accurate diagnosis and prompt management. Reference #1: Gadkowski, LB., Sout, J. Cavitary Pulmonary Disease. Clin Microbiol Rev. 2008 Apr; 21(2): 305-333. https://doi.org/10.1128/CMR.00060-07 DISCLOSURES: No relevant relationships by Odaliz Abreu Lanfranco, source=Web Response No relevant relationships by Sophia Binz, source=Web Response No relevant relationships by Raef Fadel, source=Web Response No relevant relationships by Daniel Ouellette, source=Web Response No relevant relationships by Aula Ramo, source=Web Response

Isolation and deisolation of patients admitted with presumptive pulmonary tuberculosis. Can it be shortened?

Objectives:To determine the ideal number of sputum acid-fast bacilli (AFB) smears and polymerase chain reaction (PCR) required for discontinuing tuberculosis (TB) isolation among patients with suspected pulmonary TB.Methods:This was a single-center, record-based retrospective study of all admitted patients diagnosed with culture-proven pulmonary TB between 2010 and 2018. The study was conducted at Prince Sultan Military Medical City (PSMMC) in Riyadh, Saudi Arabia, a large tertiary care center consisting of 1,200 beds. Data were obtained from our TB notification records. Patients with smear-positive TB were investigated. Only the first 3 sputum smears for AFB were included in the analysis. The PCR results for Mycobacterium tuberculosis (MTB) were also included in the study. The incremental yield of the second and third smears was assessed.Results:Overall, 240 patients were MTB-culture positive. A total of 126 (52.5%) patients were smear and culture positive, whereas 114 were culture positive but smear negative. Of 126 patients who were AFB smear positive, 98 (77.8%) were detected in the first specimen, 13 (10.3%) in the second specimen, and only 9 (7.1%) in the third specimen. Polymerase chain reaction for MTB was positive in 122 (96.8%) smear-positive patients. Four patients did not undergo a PCR test.Conclusion:A single Xpert MTB/resistance to rifampicin test detected all smear-positive patients, whereas the third smear did not significantly contribute to MTB isolation.

Sputum Negative Tubercular Adults Spread Infection and Disease to Their Household Children

To examine whether tuberculosis sputum negative adults can spread disease to their household children. A patient based study was conducted over a time period of one year, on children of those adults who were suspected case of “sputum smear positive” as well as “sputum smear negative” diagnosed with pulmonary tuberculosis at JNMCH, India. Various investigations like tuberculin test, chest X-ray, fine needle aspiration cytology (FNAC) of lymph nodes, gastric aspirate, acid-fast bacilli (AFB) sputum smear examination and others were done to attain the goal of this study. Out of 129 children, 69 were in household contact of sputum smear positive and 60 in contact of sputum smear negative adults. Forty children were found to be Mantoux positive; of which the ratio of children that were in contact of sputum positive adult to those in contact of sputum negative adult was 2:1 (27 vs 13). A small percentage (6%) of asymptomatic children was found to be diseased. Sputum positivity, low socio-economic status as well as less than 3 years of age exhibited strong association with infection as well as disease; nonetheless the number of infected and diseased children in sputum smear negative group is not negligible. A considerable number of screened children that were in contact with sputum negative tubercular adult were found to be infected as well as diseased; hence this group should not be ignored. A portion of Mantoux positive children were found to be asymptomatic and one-third of diseased children were Mantoux negative, so Mantoux cannot be taken as a gold standard for diagnosis of tuberculosis.

Tuberculosis in Children Aged 0-5 Years at the University of Port Harcourt Teaching Hospital (UPTH), Nigeria - How Common is HIV in Children with Tuberculosis

Background: Tuberculosis (TB) is a leading cause of death in young children and the risk of progression from infection to disease is higher in the very young especially among those with Human Immunodeficiency Virus (HIV) infection. This study therefore aimed to examine the method of TB diagnosis and how common HIV infection is among children 0-5 years with tuberculosis at the University of Port Harcourt Teaching Hospital (UPTH).&#x0D; Methods: Information of children aged 0-5 years from 1st January, 2011 to 31st December 2014 were retrieved from the TB register of the Directly Observed Treatment Short course (DOTS) clinic of UPTH. This included the age, sex, HIV status, Sputum AFB status, method of diagnosis of tuberculosis and the treatment outcome of the patients. Ethical approval for the study was obtained from the Research and Ethics committee of the University of Teaching Hospital.&#x0D; Results: Three hundred and thirty five children were treated for TB and 179 (53.43%) of them were aged 0-5 years. There were 93 (51.96%) males and 86 (48.04%) females, with male: female ratio of 1.08:1. Their mean age was 1.96 ±1.45. The sputum or gastric lavage of 21 (11.73%) were positive for acid fast bacilli (AFB). The common method of TB diagnosis was clinical/ radiological method and this constituted 158 (88.27%) of the patients with TB. Ninety (50.28%) children with TB were less than one year of age and there was no statistical significant relationship between age and method of TB diagnosis (x2 = 2.78, p = 0.249). More males 93 (51.96%) than females 86 (48.04%) had TB but more females 13 (61.90%) than males 8 (38.10%) were AFB positive, however, these were not statistically significant. (x 2 = 1.26 p-value = 0.262). Seventy two (40.22%) of the children with TB were HIV positive. One hundred and thirty five (75.42%) of the children recovered following treatment while 44 (24.58%) were referred to Dots centres closest to the patients. No child died.&#x0D; Conclusion: The prevalence of TB among under-fives especially among infants is high. Clinical and radiological methods were the common methods of TB diagnosis. HIV prevalence among children with TB was lower than expected by the authors, however, the treatment outcome was good. Re-training of clinicians to improve their expertise on clinical diagnosis of TB and a more in depth search of TB in the community among children 0-5 years who are HIV sero-negative with persistent cough is advocated.

Aetiological Evaluation of Pleural Effusion in a Selected Hospital

Introduction: Pleural effusion is a common clinical manifestation of varying aetiology. Its outcome varies according to underlying aetiology. The causes and prognosis vary between developed and developing countries.&#x0D; Objectives: To find out the most common causes of pleural effusion in a tertiary care hospital of Bangladesh.&#x0D; Materials and Methods: Total 50 patients were enrolled in the study during the period from January 2014 to November 2015 in combined military hospital, Dhaka. Informed written consent was obtained from all patients under the study, explaining the risk benefits and objectives of the study before sampling. Data were collected using a structured questionnaire containing all the key variables along with radiological, laboratory and pleural fluid analysis report. Data presented as frequency and percentage and Chai-square test was performed by using SPSS 23.0.&#x0D; Results: Patients' mean age was 48.28 ± 12.53 years and ranged from 12 to 70 years where half of them were above 50. Male-female ratio was 1.63:1. Sixty five percent of the patients had positive smoking history. Persistent cough, fever and weight loss were the main presenting symptoms. Radiological findings revealed 50% had isolated right-sided pleural effusion and laboratory investigation found 28% cases ESR value 50-100 mm in 1st hour. Pleural fluid examination revealed 75% patient had straw coloured pleural fluid. Sputum for Acid-Fast Bacilli and other relevant investigations revealed 44% patients had tuberculosis, 16% had pneumonia, 8% had malignancy and 24% had other causes of pleural effusion.&#x0D; Conclusion: This study revealed that the tuberculosis is the predominant cause of pleural effusion followed by pneumonia and malignancy.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.13(2) 2017: 15-17

Radiological screening for neurocysticercosis in asymptomatic siblings of children with neurocysticercosis: An observational cohort study

Introduction: Neurocysticercosis (NCC) is the most common helminthic infection of the central nervous system and a leading cause of acquired epilepsy worldwide. Tuberculosis (TB) is transmitted through droplet infection to index pediatric case from only sputum acid-fast bacilli -positive patients while NCC in an index child can result from fecal–oral route from other family members who are Taenia carriers or through autoinfection as well. Objective: Similar to universal practice of TB screening of asymptomatic family members with chest X-ray which poses radiation hazard, radiation-free radiological screening by magnetic resonance imaging (MRI) brain of asymptomatic siblings of children with NCC was carried out in the present study in addition to evaluation of family members for taeniasis. Methods: Siblings (between 1 and 18 years of age) of children attending the pediatric NCC clinic at a tertiary care hospital in Chandigarh, India, with clinically suspected and radiologically confirmed the diagnosis of NCC, were enrolled. Contrast-enhanced MRI brain was obtained free of cost to detect the presence of asymptomatic NCC in siblings enrolled in the study. Stool analysis of family members of children with NCC was carried out to detect Taenia solium carriers. Results: Of 39 enrolled asymptomatic siblings, 4 (10.3%) children were detected to have solitary intraparenchymal NCC lesion. Of the aforementioned four siblings, 3 (75%) had viable lesions, while 1 (25%) had calcified lesion. Only 2 (1.7%) of 118 stool samples of family members tested were positive for T. solium eggs. Conclusions: The results from the present study suggest clustering of NCC cases in the family and that majority of children with NCC may continue to remain asymptomatic. Targeted family screening for NCC in asymptomatic family members of children with NCC may prove more cost effective than routine mass screening. Based on the results of this study, targeted deworming of community food handlers and caution in conducting routine deworming of children are suggested.

SUN-608 A Rare Miliary Tuberculosis-Like Presentation of Papillary Thyroid Cancer: A Case Report with Literature Review

Papillary thyroid cancer (PTC) is the most common thyroid cancer with a very favorable prognosis [1]. It commonly presents as a palpable thyroid nodule or an incidental finding of thyroid nodule(s) seen on imaging. The most common site of metastases in PTC is lung, however, the incidence is very low. Presence of metastasis can drastically affect the prognosis of PTC [2]. We discuss here a case of an asymptomatic 34-year-old male, who initially presented with positive tuberculin skin test and was found to have diffuse micronodular pulmonary disease on chest imaging. Initially being diagnosed with pulmonary TB, he received 6 months of empiric anti-tuberculous therapy, although, repeated sputum and blood cultures for acid-fast bacilli remained negative. However, patient had no improvement of pulmonary lesions on interval imaging. Another interesting incidental finding, seen on lung CT, was the presence of multinodular appearance of the thyroid gland which prompted further imaging of the neck. CT scan of the neck showed multiple enhancing necrotic masses in the right thyroid gland with similar lesions in cervical lymph nodes. Considering the patient’s preliminary diagnosis of pulmonary TB, these lesions were thought to be secondary to tuberculosis. However, given that different types of thyroid malignancies can have a similar presentation, further workup was initiated. Subsequent FNA was positive for PTC on the right thyroid nodule. A total thyroidectomy with neck dissection was performed and confirmed the presence of a 2 cm PTC with cervical lymph node metastases. Post-operative non-stimulated thyroglobulin was very high at 2858. Thyroglobulin antibody was negative. The post radioactive iodine therapy (RAI) whole body scan (WBS) showed impressive bilateral lung uptake. Widespread pulmonary nodules, similar to that seen in miliary TB, is a rare initial presentation of PTC. However, as our case highlights, the added presence of thyroid nodules should prompt further investigation to rule out PTC as the cause of pulmonary lesions. 1. Aschebrook-Kilfoy, B., et al., Thyroid cancer incidence patterns in the United States by histologic type, 1992-2006. Thyroid, 2011. 21(2): p. 125-34. 2. Lang, B.H., et al., Staging systems for papillary thyroid carcinoma: a review and comparison. Ann Surg, 2007. 245(3): p. 366-78.