AFB Culture Research Articles

Evaluation of Gene Xpert as compared to conventional methods in diagnosis of Female Genital Tuberculosis

To evaluate Gene Xpert for diagnosis of Female Genital Tuberculosis (FGTB) as compared to conventional methods. Study DesignIt was a prospective study conducted over 167 cases of infertile female genital tuberculosis (FGTB) diagnosed on composite reference standard (CRS) (smear for AFB, histopathological evidence of epithelioid granuloma or definite or possible findings of tuberculosis on laparoscopy). All women underwent endometrial biopsy for AFB microscopy, culture, gene Xpert, PCR and histopathology) and laparoscopy and hysteroscopy for diagnosis and prognostication of disease. The results of Gene Xpert were compared with conventional methods in detection of FGTB. All patients were treated with 6 months course of rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol (E) (RHZE for 2 months, RHE for 4 months) using directly observed treatment short course strategy. ResultsMean age, parity, body mass index and history of contact was 28.3 years, 0.28, 22.9 Kg/m2 and 38.92% respectively. Primary infertility was seen in 87.42% cases with mean duration of 2.42 years. Menstrual dysfunctions, abdominal or pelvic pain and lump were seen in 38.92%, 14.37% and 10.77% cases. Abnormal vaginal discharge and adnexal mass were seen in 28.14% and 13.17 % cases. On diagnostic laparoscopy, definite findings of tuberculosis (beaded tubes, tuebrcles and caseous nodules) were seen in 96 (57.48%) women while probable findings of tuberculosis (pelvic or abdominal adhesions, hydrosaplinx, tubo-ovarian mass, pyosalpinx) were seen in 81 (48.50%) women.On laboratory investigations, positive AFB on microscopy or culture was seen in 2.99% casess, PCR was positive in 47.90% gene Xpert was positive in 18.56% cases while epitheloid granuloma was seen on histopathology in 16 (9.58%) cases. Gene Xpert had sensitivity of 35.63%, specificity of 100%, positive predictive value of 100% and negative predictive value of 58.82% and diagnostic accuracy of 66.47% in the present study. ConclusionGene Xpert is a very useful test to rule in tuberculosis whereas when it is negative it is not a good test to rule out tuberculosis.

A CASE OF E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY IN AN INFREQUENT VAPE USER

SESSION TITLE: Medical Student/Resident Tobacco Cessation and Prevention Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: We present a case that shows e-cigarette or vaping product use associated lung injury (EVALI) can occur even with infrequent use. CASE PRESENTATION: A 50-year-old woman presented with a 1-week history of malaise, shortness of breath, and dry cough. She admitted to consuming a THC containing vaping product 2-3 times a month for the past 1 year. Chest X-ray showed diffuse bilateral pulmonary infiltrates. CT Chest showed extensive centrilobular nodular opacities with small patchy consolidations in bilateral upper and lower lobes. Influenzae and HIV were negative. Serology testing for vasculitic and connective tissue disorders was negative. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy of the right upper lobe was performed. Gram stain with culture, fungus culture, AFB culture, and Legionella were all negative. Histopathology showed evidence of focal organizing pneumonia and numerous foamy macrophages, which are findings described in EVALI. GMS and AFB stain were negative for infectious microorganisms. No malignant cells were seen on cytology. Given the constellation of findings, we concluded this was EVALI. She was started on prednisone and advised to refrain from vaping. On 6-week follow up in our outpatient pulmonary clinic, she endorsed complete resolution of symptoms. A repeat CT of the chest showed dramatic improvement with near complete resolution of the prior opacities. DISCUSSION: EVALI is a diagnosis of exclusion. The characteristic bilateral pulmonary infiltrates and the histopathology of foamy macrophages that are described in EVALI can be seen in other forms of lung diseases. Thus, confirming vaping history is vital to the diagnosis. In a case series of patients diagnosed with EVALI, the vast majority of patients admitted to at least daily use. This case reminds us that infrequent use of vaping can lead to EVALI as well. CONCLUSIONS: Given the popularity of e-cigarette and vaping use, clinicians should be aware that infrequent vaping use can lead to EVALI. We encourage a push for medical professionals to incorporate e-cigarette or vaping use as part of regular social history intake, regardless of clinical presentation. Due to the various factors that may prevent a patient from being open with their use, it is the role of the clinician to broach this topic in a nonjudgmental and confidential manner. Reference #1: Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin - preliminary report. N Engl J Med 2019; https://doi-org.proxy.lib.fsu.edu/10.1056/NEJMoa1911614. Reference #2: Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019 MMWR Morb Mortal Wkly Rep. 2019 Oct 18; 68:919–927 DISCLOSURES: No relevant relationships by Kristina Akopyan, source=Web Response Speaker/Speaker's Bureau relationship with GlaxoSmithKline Please note: $1001 - $5000 Added 04/20/2020 by Alberto Fernandez, source=Web Response, value=Consulting fee No relevant relationships by Abdul Siddiqui, source=Web Response

MYCOBACTERIUM PORCINUM CAUSING A FALSE-POSITIVE QUANTIFERON TB-GOLD TEST

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mycobacterium (M.) porcinum is a rapidly growing nontuberculous mycobacterium that is genetically related to M. Fortuitum. It has been detected in drinking water and fresh vegetables. In isolation, M. porcinum is considered to be commensal; however, true infections such as cellulitis, peritonitis, catheter-related infection and rarely pneumonitis have been reported secondary to M. Porcinum. We discuss the case of a 69 year old male who was infected with M. Porcinum and tested positive for Quantiferon TB-Gold (QFT). This case report brings to attention that despite the increased reliance on QFT for tuberculosis (TB) diagnosis, it is important to be mindful of its limitations and the possibility of an underlying non-tuberculous mycobacterium infection. CASE PRESENTATION: A 69-year-old male, with a history of COPD and long-term smoking presented with a persistent cough and shortness of breath for the past three months. He was treated for bronchitis without improvement. He denied any fever, chills, rigors or weight loss. CT scan of the chest showed a tree in bud appearance, raising concern for an atypical mycobacterial infection. Sputum for AFB stains were negative along with the Mycobacterium tuberculosis PCR assay. However, the QFT was positive. Further, after two weeks of incubation, AFB cultures were positive for M. Porcinum. The patient was subsequently started on rifampin, clarithromycin and amikacin with symptomatic improvement. DISCUSSION: The QFT gold is an ELISA measuring IFN-γ specific to M. tuberculosis peptides such as ESAT6, CFP-10, and TB7.7. These are present in M. tuberculosis but absent in BCG and other non-tuberculous mycobacterium. Unlike the tuberculin skin test, which measures a delayed hypersensitive reaction to the purified protein derivative present in M. tuberculosis and many atypical mycobacteria, the QFT gold test is an in vitro test that is more specific to M. tuberculosis. However, some tuberculous mycobacterium including M. Fortuitum and M. bovis also harbor ESAT 6, CFP 10, and TB7.7 and can produce falsely-positive QFT gold tests. As demonstrated in our patient, we consider M. porcinum to be a true pathogen. He had concomitant advanced COPD and showed evidence of a tree-in-bud appearance that is typically seen in an atypical Mycobacterium infection. After completing treatment with antibiotics, repeat sputum cultures have been negative. Infections from M. Porcinum have only been reported in a few case reports; however, false positive QFT tests secondary to M. porcinum have yet to be reported in literature. CONCLUSIONS: Although M. porcinum is usually considered commensal, it was regarded as a true pathogen in our patient, as evidenced by the tree in bud appearance on CT, positive M. Porcinum cultures, and a negative Mycobacterium tuberculosis PCR assay. Thus, we consider the QFT in our patient to be falsely-positive. Reference #1: Brown-Elliott BA, Wallace RJ, Tichindelean C, et al. Five-year outbreak of community- and hospital-acquired Mycobacterium porcinum related to public water supplies. J Clin Microbiol 2011;49:4231–8. DISCLOSURES: No relevant relationships by Joseph Leon, source=Web Response No relevant relationships by Mohan Rudrappa, source=Web Response No relevant relationships by Sanket Shah, source=Web Response No relevant relationships by Kunal Shah, source=Web Response

ASCITES OF THE DIAPHRAGM

SESSION TITLE: Medical Student/Resident Pediatrics Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Rhabdomyosarcoma is more common in pediatric populations, but remains rare, representing only 3 percent of pediatric cancers. It is typically diagnosed in children less than 6 years of age, and tends to occur in the head and neck, GU tract, and extremities, with different histologic subtypes having a predilection for certain areas. CASE PRESENTATION: We present a 12-year-old girl with 1.5 weeks of cramping upper abdominal pain, nonbilious, abdominal distention, non-bloody emesis, and watery diarrhea. She also reported fatigue and 10 pound weight loss. On presentation, she was afebrile and vitals were within normal limits. Exam was notable for a distended abdomen with positive fluid wave and tenderness in the upper abdomen, as well as inguinal and axillary adenopathy. Initial labs revealed hemoglobin 12.4, platelets 718, AST 48, albumin 2.3, lipase 68. Abdominal ultrasound showed a large amount of ascites. Subsequent labs showed ESR 60, CRP 13.65, LDH 666, and uric acid 6.1. Repeat CT abdomen/pelvis with intravenous and oral contrast showed malignant ascites with focal nodular soft tissue along the left hemidiaphragm as well as in the anterior abdomen, and left pleural effusion. A paracentesis was performed with 3 L of yellow, cloudy fluid obtained with ˜5000 red blood cells, 1120 white blood cells, albumin 2.1, amylase 27, glucose 70, protein 3.9, triglyceride 28. Cytology showed reactive vs neoplastic atypical cells, degenerating cells, reactive mesothelium and inflammatory cells. Quantiferon and AFB cultures were negative. Biopsy of the left hemidiaphragm soft tissue mass showed alveolar infiltrating fibrocollagenous rhabdomyosarcoma. She is currently undergoing palliative radiation and chemotherapy. DISCUSSION: Rhabdomyosarcomas are cancers that originate from rhabdomyoblasts, making them more common in children. There are 4 subtypes: embryonal (59%), alveolar (21%), anaplastic (1%), and undifferentiated (8%). Alveolar rhabdomyosarcomas typically involve large muscles of the trunk and extremities, and tend to occur in individuals ages 10-25. They grow rapidly, and require more intensive therapy. Diagphragmatic rhabdomyosarcomas are rare, with 41 cases noted from 1868 to 2005 in a review of literature. The majority of cases present with thoracic symptoms, rather than abdominal symptoms. A recent study from the Italian Soft Tissue Sarcoma Center identified 150 children over 30 years with rhabdomyosarcoma, with only 18 of those presenting with ascites. CONCLUSIONS: We present a case of alveolar diaphragmatic rhabdomyosarcoma with only 41 cases diagnosed worldwide. What makes this case more rare is the presenting complaint of abdominal symptoms. Our case highlights that these entities can present a diagnostic challenge, given their ability to affect less common areas and grow insidiously until presenting with atypical symptoms. Reference #1: Cada M, et al. Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm. Journal of Pediatric Surgery. October 2006. 41(10):1722-6 Reference #2: Di Carlo, D., Ferrari, A., Toffolutti, T., Milano, G. M., Manzitti, C., Ruggiero, A., ... Bisogno, G. (2019). Prognostic role of pleural effusion or ascites in localized rhabdomyosarcoma. Pediatric Blood and Cancer, 66(11), e27932. https://doi.org/10.1002/pbc.27932 Reference #3: Raney RB, Anderson JR, et al. Soft-tissue sarcomas of the diaphragm: a report from the Intergroup Rhabdomyosarcoma Study Group from 1972 to 1997. Journal of Pediatric Hematology Oncology. 2000 Nov-Dec; 22(6):510-4 DISCLOSURES: No relevant relationships by Holly O'Brien, source=Web Response No relevant relationships by Seif Shahidain, source=Web Response

MULTIFOCAL PULMONARY NODULAR HYPERPLASIA IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary nodular lymphoid hyperplasia (PNLH) is a rare lympho-proliferative disorder characterized by benign polyclonal lymphoid proliferation. We describe a case of a 44-year-old woman with biopsy proven multifocal pulmonary nodular lymphoid hyperplasia in the setting of SLE. CASE PRESENTATION: 44-year-old woman presented to the emergency room with complaints of intermittent pleuritic chest pain and exertional dyspnea for 3 months. Review of systems was positive for joint pains and morning stiffness. Physical examination was remarkable for tenderness and swelling at proximal interphalangeal joints. Cardiac work up including electrocardiogram, troponin levels and echocardiogram was unremarkable. CT scan of chest with contrast showed numerous bilateral cavitary ground glass opacities measuring about 1-2 cm in size. Transbronchial biopsy was non-diagnostic. A subsequent video-assisted thoracoscopic surgical biopsy revealed nodular lymphoid hyperplasia. Specimen was negative for malignancy, granulomatous disease or vasculitis. Lymphoma was also ruled out by flow cytometry. AFB, fungal and bacterial stains and cultures were negative. Hepatitis panel and HIV testing was negative. Rheumatologic work up showed negative rheumatoid factor and positive ANA, anti-SSA, anti-dsDNA Ab, anti smith and anti-U1-RNP antibodies. Inflammatory markers, ESR and CRP, were elevated. She was evaluated by rheumatology and further history revealed presence of alopecia and nasal sores in addition to serositis (pleuritis) and arthritis. Her clinical picture and serologies met the diagnostic criteria for SLE. DISCUSSION: Pulmonary lymphoid nodular hyperplasia is a rare benign lymphoproliferative disease. It is relatively more common in women and often an incidental finding on imaging. Most patients are asymptomatic, however symptoms such as cough, chest pain or dyspnea can be present. Diagnosis is made by surgical biopsy. It is essential to rule out malignancy, particularly mucosal associated lymphoid tissue lymphoma and infectious etiologies such as bacterial or fungal pulmonary infections. So far PNLH has been described in patients with Sjogren’s disease, without conclusive association. Most common pulmonary manifestation in SLE is pleurisy. Interstitial lung disease (ILD) is less common in SLE and is seen in patients who have anti–U1-RNP antibodies. Imaging findings are nonspecific; however, ground-glass opacities or consolidations may be present. PNLH has not been described in association to or as a manifestation of SLE in medical literature. There is paucity of data for correlation and larger studies are required to study this potential association. CONCLUSIONS: Pulmonary nodular lymphoid hyperplasia is a rare benign lymphoproliferative disorder. After malignancy and infectious etiology is ruled out autoimmune disease should be considered in patients with PNLH. Further work is warranted to establish this relation. Reference #1: Abbondanzo SL, Rush W, Bijwaard KE, Koss MN. Nodular lymphoid hyperplasia of the lung: a clinicopathologic study of 14 cases. Am J Surg Pathol. 2000;24(4):587–597. Reference #2: Song MK, Seol YM, Park YE, et al. Pulmonary nodular lymphoid hyperplasia associated with Sjögren's syndrome. Korean J Intern Med. 2007;22(3):192–196. doi:10.3904/kjim.2007.22.3.192. Reference #3: Quadrelli SA, Alvarez C, Arce SC, et al: Pulmonary involvement of systemic lupus erythematosus: analysis of 90 necropsies. Lupus 2009; 18: pp. 1053-1060 DISCLOSURES: No relevant relationships by William Han, source=Web Response No relevant relationships by Immad Munawar, source=Web Response No relevant relationships by Theresa Nicol, source=Web Response

A CASE OF MAC IN A PATIENT WITH CHRONIC SILICOSIS

SESSION TITLE: Medical Student/Resident Occupational and Environmental Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Our patient is a 32-year-old male with chronic silicosis who presented with one week of worsening dyspnea and cough in the setting of a 40 pound weight loss over 3 months. CASE PRESENTATION: The patient was diagnosed with silicosis in 2015 (Image 1) in the setting of prolonged work with cutting porous stone without use of PPE; he had a negative mycobacterial work-up then. He was lost to follow-up and continued to work until one week prior to this presentation. On hospital presentation he was found to be febrile, severely cachectic, using accessory muscles for respiration, and with fine bilateral inspiratory crackles diffusely. He was subsequently admitted to the ICU for hypercapnic and hypoxemic respiratory failure requiring non-invasive ventilation (NIV). CT findings suggested progressive massive fibrosis (PMF) with eggshell calcifications of mediastinal lymph nodes; however, a cavitary infectious process could not be ruled out (Image 2 and 3). He was started on empiric antibiotics for bacterial pneumonia. Laboratory testing revealed negative bacterial, fungal, and viral sputum/blood cultures. He showed marginal improvement in respiratory status after initiating NIV and completing antibiotics. Although the initial AFB sputum smears were negative, two weeks later two separate AFB cultures each grew Mycobacterium Avium Complex (MAC). He was fully weaned off NIV after starting anti-mycobacterial therapy. Given the imaging and his clinical improvement, this decompensation was thought to be secondary to PMF with MAC superinfection. DISCUSSION: Silicosis occurs following chronic occupational exposure to aerosolized silica from mining, stone cutting, or sandblasting. Patients often are asymptomatic despite abnormal x-ray findings. Imaging of chronic silicosis typically follows nodular patterns of inflammation (which was noted on our patient's initial diagnosis) and in more acute presentations ground-glass opacities and crazy paving have been described. Our patient's clinical presentation and CT findings of diffuse coalescent densities and cavitations led us to consider PMF and mycobacterial disease over simple silicosis. PMF is a rare, and in most cases irreversible, complication of silicosis defined as conglomeration of dense fibrosis preferentially involving the upper lung lobes. Eggshell calcifications of lymph nodes are often described. Mycobacterial infection is also a rare complication of silicosis, classically with mycobacterium tuberculosis (TB); however there have been many case reports with silicosis patients developing MAC infections. These mycobacterial infections present with constitutional and TB-like symptoms such as weight loss. CONCLUSIONS: Progressive massive fibrosis in silicosis is a rare complication that leads to severe structural lung disease and respiratory failure. Mycobacterial superinfection, including MAC, should be considered in decompensated patients with silicosis. Reference #1: Jiro Fujita,Takumi Kishimoto,Yuji Ohtsuki,Eriko Shigeto,Takayuki Ohnishi,Masahiro Shiode,Yasufumi Yamaji,Ichizo Suemitsu,Ichiro Yamadori,Shuji Bandoh,Kazutaka Nishimura,Toshiharu Matsushima,Toshihiko Ishida. Clinical features of eleven cases of Mycobacterium avium-intracellulare complex pulmonary disease associated with pneumoconiosis. Respir Med. 2004 Aug;98(8):721-5. DISCLOSURES: No relevant relationships by Neel Bhan, source=Web Response No relevant relationships by Nicola Hanania, source=Web Response No relevant relationships by Lauren Nicholas Herrera, source=Web Response No relevant relationships by Hal Zhang, source=Web Response

Analysis of Smear Microscopy and Culture Conversion Results in Multidrug-Resistant Tuberculosis Patients with and without Type 2 Diabetes Mellitus

The World Health Organization (WHO) recommended microscopic AFB smear examination and culture as follow-ups to the response of MDR TB therapy. Analyzed the results of microscopic AFB smear and culture conversion as well as treatment outcome in Multidrug-Resistant Tuberculosis (MDR-TB) patients with and without Diabetes Mellitus (DM). This is a retrospective study involved 70 MDR-TB patients with (27 patients) with DM and without DM (43 patients) who had microscopic AFB smear and culture results at the start of the follow-up therapy. This research was conducted at Labuang Baji Regional Public Hospital, Makassar, from June to July 2019, used medical records of MDR-TB patients the period of June 2016 to December 2017. The results showed that 52 out of 70 MDR-TB patients had microscopic AFB smear and culture conversion in MDR-TB with DM (21 patients) and without DM (31 patients). The duration of microscopic AFB smear conversion in MDR TB patients with DM (3.33±0.54 months) was longer than patients without DM (2.07±0.05 months), p=0.001. While in culture conversion, there was no significant difference between MDR-TB with DM (1.28±0.64 months) and without DM (1.25±0.59), p=0.648. The recovery outcome between MDR-TB with (48.1%) and without DM (48.8%) was not significantly different. However, the output of treatment failure was greater in DM (11.2%) than without DM (2.3%), although statistically, there was no significant difference (p=0.568). Multidrug-resistant tuberculosis patients with DM experienced slower microscopic AFB smear conversion than MDR-TB patients without DM. However, in culture, there was no significant difference in the conversion period between the two groups. MDR-TB patients, both of with and without DM, had the same chance of recovery.

The pattern of pediatric tuberculosis and treatment outcomes from 2012 to 2016 in Erbil City, Iraq

Background and objective: M. tuberculosis is one of the main causes of morbidity and mortality in many countries and is considered a priority global health problem. Although it is a curable disease, every year about nine million people develop active disease, and two million die from it. This study aimed to find the pattern of tuberculosis among children in Erbil city and determine the treatment outcomes of pediatric tuberculosis. Methods: From March 2012 to March 2016, 142 patients younger than 18 years with confirmed diagnosis of tuberculosis were registered and treated at the Chest and Respiratory Disease Centre in Erbil. The diagnosis of tuberculosis was performed based on routine tests at the center. AFB smear staining, GeneXpert assay, and culture methods when required for further confirmations using L-J media. Results: The total number of the studied records of tuberculosis was 729 during five years (2012-2016). More than half (55.6%) of patients aged ≤ 18 years were males. It is evident that the number of cases is increasing with the progress of years, but the difference was not significant between the years (P = 0.534). The death rate was 9.1% among patients of the whole sample, but no significant association was detected between age and outcome and was highest (22.7%) among patients aged 7-12 years (P = 0.142). Conclusion: Tuberculosis is still a very severe disease with high mortality rates in children. Early recognition of infection associated with correct early treatment, systematic entourage investigation, and chemoprophylaxis by isoniazide in all children under five years of age is essential for attempting to reduce these prognostic indices.

Role of GeneXpert in the diagnosis of mycobacterium tuberculosis.

GeneXpert (GX) is a novel, integrated, cartridge-based, nucleic acid amplification test with an established role for rapid diagnosis of Mycobacterium tuberculosis and detection of rifampicin resistance. To evaluate the role of GX in pulmonary and extrapulmonary tuberculosis (TB) cases. A prospective study was conducted in the pulmonary medicine department of a tertiary care hospital after the Ethics Comittee permission. Data of 257 presumptive TB patients was retrieved for GX, acid fast bacilli smear and cul-ture (AFB smear and culture) and drug susceptibility test (DST). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of GX in diagnosis and determination of rifampicin resistance in pulmonary and extrapulmonary TB cases were calculated and compared with culture and DST results. Our study included 132 pulmonary and 125 extrapulmonary cases. On the basis of clinicoradiological and microbiological correlation, diagnosis of TB was confirmed in 104 pulmonary and 103 extrapulmonary cases. Out of a total of 104 pulmonary TB cases, 73 were rifampicin-sensitive and 31 were rifampicin-resistant cases. 103 extrapulmonary TB patients included 66 rifampicin-sensitive and 37 rifampicin-resistant cases. The sensitivity, specificity, PPV, NPV of GX in diagnosis and detection of rifampicin resistance in pulmonary TB was 95%, 93%, 98%, 84% and 96%, 100%, 100%, 96%, respectively. The sensitivity, specificity, PPV, NPV of GX in diagnosis and detection of rifampicin resistance in extrapulmonary TB cases was 79%, 86%, 96%, 47% and 97%, 95%, 97%, 95%, respectively. GX results are superior to smear microscopy and comparable to culture with shorter turnaround time.We recom-mend using it in routine TB diagnosis as this will expedite the management of patients with presumptive TB.

TO ASSESS THE ADVERSE EFFECT PROFILE OF SECOND LINE DRUG IN MDR TB PATIENTS

Method: Study including LPA /AFB CULTURE proven cases of MDR TB. Data will be collected from the patient attending the OPD & IPD in the Dept. of Respiratory Medicine.
 Result: Out of 200 patients 71% were of male its shows that MDR T.B. more prevalent among males and female 29%. Out of 200 patients most of the patients come under 10-15 Kg/m2 BMI, so its shows that 64.5% patients comes it and disease more prevalent among under nutrition. Out of 200 patients, the present study shows that gastrointestinal side effects are the most common 42%. 09 patients have renal toxicity and 08 patients have Arthalgia and 06 patients have cutaneous reactions and 11 patients developed hepatitis and 07 patients have some psychiatric illness and 07 patients developed hearing defect.
 Conclusion: The present study shows that gastrointestinal side effects are the most common 42%. 09 patients have renal toxicity and 08 patients have Arthalgia and 06 patients have cutaneous reactions and 11 patients developed hepatitis and 07 patients have some psychiatric illness and 07 patients developed hearing defect. Overall, these findings emphasize the importance of continuing the systematic surveillance of M. tuberculosis isolates to monitor the trends of drug resistance in different patient categories.
 Keywords: Adverse, Second line & MDR TB.

Predominance of Streptococcus pneumoniae among TB patients complicates Dots chemotherapy at infectious diseases hospital Kano, Northwest Nigeria

Directly observed treatment Short course regimen has been know to be efficacious in the chemotherapy management of tuberculosis. However, co- infection with other opportunistic bacteria could limit this success to the level of clinical suspecting the emergence of false positive multidrugs resistant TB among the patients which in many cases can lead to establishment of erroneous treatment schedule. Accordingly this facility based surveillance monitors co-infection with other bacteria in TB patients attending Dots clinic at IDH Kano, Nigeria with view to ascertaining the drug susceptibility so as to proffer better chemotherapy strategies. A total 35 non - duplicated positive AFB sputum sample collected from patients with pulmonary tuberculosis on Dots where processed according to standard bacteriological procedures including macroscopic, culture and microscopic examination using both AFB gram staining and culture methods for screening and isolation of other bacterial pathogens. These were confirmed biochemically. Overall 54.3% of the patients were Still AFB positive, Streptococcus pneumoniae and Staphylococcus species we’re predominat in up to 84.2% and 15.8% of the patients respectively. This study indicated secondary bacterial pathogenesis with pulmonary symptoms resembling TB among the patients including those that were even isolated for being refrectory to Dots an false positive conclusion of drug resistant TB. However, ofloxacin and ceftriaxone which show appreciable potencies against secondary bacterial pathogens identified where used to treat successfully, patients claimed posses drug resistant TB. It’s imperative that, success of Dots therapy could be improved by augumentin with very potent non TB antibacterial such as Streptococcus pneumoniae regimen. Keys. TB.

SUN-166 Primary Adrenal Insufficiency Caused by Underlying Tuberculosis

IntroductionPrimary adrenal insufficiency (AI) is a rare endocrine disorder affecting 1 in 100,000 people. Primary AI is a gradual destruction of the adrenal cortex. Etiology includes autoimmune, tuberculosis, histoplasmosis, blastomycosis, adrenal metastases, primary adrenal tumors, and opportunistic infections of HIV. Since aggressive treatment of TB, the incidence of TB adrenalitis has significantly declined, now accounting for 20% of reported cases where as autoimmune causes of AI account for 70%. Most common symptoms are non-specific, and diagnosis is often delayed, with patient initially presenting with a life-threatening adrenal crisis.CasePatient is an incarcerated 65 y/o African American male with PMHx of hypothyroidism who was admitted to the hospital for AMS after being found unresponsive in his prison cell. On admission, patient was febrile, hypotensive and tachycardic. He looked disheveled, confused, and lethargic. Other exam findings were negative.Lab results revealed WBC 11.7/μL, serum sodium 116 mmol/L, serum potassium 5.2 mmol/L, serum glucose 68 mg/dL, serum osmolality 237mOsm/kg, TSH 26.3mIU/L, and random cortisol 1.6ug/dL. ACTH stimulation test revealed pre-challenge cortisol levels 5.1ug/dL, 30-minute 4.9ug/dL and 60-minute 4.5ug/dL. ACTH 1271 pg/mL (normal range 7.2-63.3pg/mL). A normal response is a stimulated cortisol level > 18ug/dl. Chest x-ray revealed left lower lobe pneumonia.Clinical signs/symptoms and labs were consistent with primary AI. Adrenal crisis was most likely precipitated by underlying pneumonia. Workup was negative for 21-Hydrolase Antibodies, HIV, CMV, and histoplasmosis. However, QuantiFERON-TB Gold Test was positive. Abdominal CT revealed bilateral enlarged non-enhancing adrenal nodules with coarse calcifications. Biopsy of right adrenal gland revealed necrotizing caseating granulomatous inflammation. Biopsy was negative for isolated aerobic, anerobic, fungal organisms, AFB, and mycobacterium PCR.Due to current findings and high suspicion of TB adrenalitis, patient is currently being treated as culture-negative tuberculosis along with PO hydrocortisone for underlying AI.DiscussionAdrenal tuberculosis is a rare cause of primary adrenal insufficiency in developed countries. There should be high suspicion for AI when a patient presents with hypotension, hyponatremia, hyperkalemia and/or hypoglycemia. In this case, although patient did not have a positive AFB culture, he did have a positive QuantiFERON-TB Gold Test along with consistent findings on CT and biopsy. Thus, case was concluded to have high suspicion of primary AI secondary to underlying untreated tuberculosis. Prompt treatment with antituberculosis medication, appropriate steroid therapy, along with monitoring of adrenal function, underlying adrenal insufficiency may be reversible if detected in early stages and decrease mortality.

Comparison Study of GENEXPERT versus TB MGIT Culture in Extra Pulmonary Tuberculosis

Aims and objectives: To compare the diagnostic yield of Extra Pulmonary Tuberculosis, in terms of MTB isolation & detection of drug resistance via GENEXPERT & MGIT-DST culture methods. Materials and Methods: This was a prospective observational study carried out in Department of Pulmonary medicine, D.Y. Patil Hospital, Navi Mumbai. Study participants were patients above 18 years of age who had extra pulmonary tuberculosis and who were not already on Anti tuberculosis treatment in D.Y. Patil Hospital, Nerul, Navi Mumbai and willing to participate in the study and meeting all the inclusion criteria of the study. Study duration was from the date of approval by institutional ethics committee to October 2019.Sample size was 150 patients satisfying the inclusion criteria. Results: In our study, 28 % of all extra pulmonary samples were tested positive for TB MGIT culture out of which 35.2 % showed Resistance to 1st line ATT drugs on DST where as 39.33% was tested positive with Gene expert out of which 22.47% showed Rifampicin Resistance. Sensitivity of MGIT was 28.00 % and specificity was 39.50 %.Sensitivity of Genexpert was 39.33% and specificity was 26.5%. Conclusion: Our findings suggest that Gene Xpert may have a role in EPTB diagnosis in addition to PTB, particularly in low income/high-burden settings, where facilities for mycobacterial culture are limited. But Gene Xpert can detect only Rifampicin resistance where as DST by BACTEC MGIT AFB Culture detects other ATT drugs sensitivity too. Also the test results of MTB detected in GeneXpert in extra pulmonary samples was shown as low and very low based on the CT range (high, 28) as most of the extra pulmonary samples are pauci bacillary; hence the result is not totally reliable. Therefore, it should be confirmed by phenotypic DST by BACTEC MGIT Culture.

Corelation of clinical and radiological parameters with microbiological diagnosis in spinal tuberculosis: A cross sectional study

Background: Tuberculosis is the most common and deadly multisystem disease affecting the developing world. Its incidence and prevalence is on a rise in developing countries. About 10% of pulmonary tuberculosis patients present with extra-skeletal involvement of which spine is most commonly affected. It can cause neural compromise, bone destruction and spinal deformity.Material and Methods: Our study includes 30 patients with signs and symptoms of potts spine which were evaluated further by a similar protocol of investigations in last 2 years and their demographic data, clinical, radiological and microbiological findings are reported. The clinical parameters taken into consideration were fever, cough, backache and neurological complaints and any positive findings on plain radiographs of relevant spinal region and their relative presence or absence were correlated with confirmatory diagnosis on AFB culture and gene Xpert.Results: Fever & backache were most common complaints present in 19 (63.3%) of subjects. Neurological complaints were present in 15 (50%) of subjects followed by cough in 9 (30%) of subjects.22 subjects showed some finding suggestive of potts spine on plain radiograph.18 (60%) subjects were positive for MTB on culture from biopsy taken.23 (76.7%) subjects were having gene expert test positive while 7 (23%) subjects were having negative gene expert test. Total 7 out of 30 subjects had multi drug resistance (MDR) out of which 1 subject was HIV + ve while 6 were HIV –ve.2 subjects had already started the empirical ATT regimen from the peripheral centres.Conclusion: Spinal tuberculosis is still prevelant in large numbers in developing countries which remains largely undetected in most of the health centres. Our study aims to find out the role of various common clinical symptoms individually as well as combined with radiological studies as screening tests in clinical detection of spinal tuberculosis and thus faster management in its direction.

Rapid detection of mycobacterium tuberculosis complex by real-time polymerase chain reaction (PCR) in pulmonary and extra-pulmonary samples in Casablanca, Morocco

Introductionthe laboratory diagnosis of tuberculosis (TB) relies mainly on conventional techniques. However, it either lacks sensitivity or it is time-consuming. This study aims to evaluate the use of real-time polymerase chain reaction (PCR) targeting IS6110 for Mycobacterium tuberculosis (TB) Complex (MTBC) in the routine diagnosis of TB in our laboratory.Methodsclinical samples were collected from the laboratory of bacteriology at Ibn Rochd University Hospital in Casablanca Morocco. Real-time polymerase chain reaction (PCR) results were compared to AFB smear and culture on Löwenstein-Jensen (LJ) solid media. Sensitivity, specificity, positive and negative predictive value (PPV and NPV) with 95% confidence intervals were calculated using GraphPad Prism.Resultson 171 clinical samples, the study showed positivity of microscopy, culture and real-time PCR for M. TB complex as 19%, 31%, and 32% respectively. Sensitivity, specificity, PPV and NPV for real-time PCR in pulmonary samples were 95.2%, 95.4%, 90.91% and 97.65% respectively. For extra-pulmonary samples, they were: 72.7%, 90.32%, 72.7%, and 90.3%.Conclusionour study shows the effectiveness of using real-time PCR IS6110 in pulmonary and extra pulmonary samples. Future multicentric studies could seek to evaluate the place of this technique on routine diagnosis for better management of TB in Morocco.

Diagnostic Yield of Bronchoalveolar lavage Xpert MTB/RIF Assay (Gene Xpert ® in Sputum Smear Negative Pulmonary Tuberculosis Patients – A One Year Cross Sectional Study

Introduction: Tuberculosis remains a major public health issue and is one of the top ten causes of death worldwide. Seven countries worldwide account for 64% of the total incidence and India leading the count. Only about 50-60% of the cases are sputum smear positive, while rest are sputum scare or smear negative cases. Since December 2010, WHO has recommended the use of Xpert MTB/RIF assay due to its high-quality performance, as compared to microscopy in the diagnosis of tuberculosis. The present study was done to evaluate the early diagnosis of sputum smear negative pulmonary tuberculosis patients using Xpert MTB/RIF assay test in broncho-alveolar fluid and to evaluate prevalence of rifampicin resistance in these patients.
 Methods: This was a one year cross section study conducted in a tertiary care hospital. A total of 143 suspected cases of pulmonary tuberculosis patients who were sputum smear negative were included in the study. All patients underwent bronchoscopy and the BAL specimen was subjected for Xpert MTB/RIF assay, smear by ZN staining and AFB Culture using MGIT 960 medium. The sensitivity and specificity of the Xpert MTB/RIF assay was compared to AFB culture which is considered as the gold standard method for diagnosing TB was calculated.
 Results: Majority of the patients were males (74.83%) and under the age group of 30 years (26.57%). Out of 143 suspected, the final diagnosis of PTB was done in 93 patients. Out of 93 cases of PTB, 87(93.5%) patients were Xpert MTB/RIF assay positive, 80(86.0%) were AFB culture positive and 39(41.9%) patients were AFB smear positive. The sensitivity and specificity of BAL Xpert MTB/RIF assay was 92.5% and 79.37% respectively (p <0.0001).
 Conclusion: The Xpert MTB/RIF assay is more sensitive and specific than smear microscopy for the diagnosis of PTB in sputum smear negative on specimens obtained from broncho-alveolar lavage (BAL).

Late Sterile Cyst Formation Following Use of Bioglue in Carotid Endarterectomy

Introduction - Achieving adequate suture line haemostasis is the backbone of successful vascular surgery and high-pressure sealants such as bovine serum albumin-glutaraldehyde glue (BioGlue, CryoLife Inc., Kennesaw) are available to aid successful anastomosis. BioGlue has been shown to be an important and useful adjunct in achieving suture line haemostasis however literature suggests its use is associated with psuedoaneurysm formation, thromboembolic events due to leakage through suture holes, local tissue damage and late aseptic cyst formation. We present a case of late sterile cyst formation following the use of BioGlue in carotid endarterectomy (CEA). Methods - An 88-year-old female was admitted follow left lacunar stroke with significant right arm weakness and dysarthria. Also noted was one week history of an asymptomatic, enlarging right sided neck mass. Patient had undergone a right carotid endarterectomy 9 months previously for tight 90% stenosis of the right internal carotid artery (ICA). BioGlue (BG3515-5-G, LOT 15MGV110) was used during right CEA to aid haemostasis along the suture line. Examination revealed a 5x3x2cm collection inferior to right sternocleidomastoid muscle. Patient afrebrile and inflammatory markers not raised. Duplex ultrasound of the left ICA confirmed 80% stenosis. CT angiogram of carotids showed concentric soft tissue thickening surrounding the right internal carotid artery but anterolaterally there was an irregular 26mm x 19mm x 22mm fluid attenuation component with faint marginal enhancement. There was no evidence of pseudoaneurysm. Left ICA was managed conservatively however surgical exploration of the right neck swelling was performed. Using an oblique incision to open the neck it was evident there was chronic inflammation and a superficial abscess present with connecting sinus to the patched ICA. A large amount of BioGlue was returned with 1cm area of distal patch appearing to be the central focus of possible infective process. Washout performed and deep drain placed. Results - Empirical antimicrobial therapy of 7 days intravenous teicoplanin followed by 7 days oral docycycline was initiated. All microbiological analysis on theatre specimens (routine culture, extended anaerobic culture, actinomyces and AFB culture, 16S RNA viral assay) was negative. Patient was discharged to a local stroke rehabilitation unit. Conclusion - BioGlue has both adhesive and sealant properties. It acts by formation of strong covalent bonds, within 2-3 minutes, allowing rapid haemostasis and reinforcement of friable tissues A large amount of BioGlue was returned on exploration of the neck which is similar to a case of BioGlue associated aseptic mediastinal cyst after coronary artery bypass described by Szafranek et al [1]. At present, we note no cases of late sterile cyst formation after use of BioGlue in vascular surgery. Agents used to aid haemostasis should be used with caution with minimal volume application used to achieve desired effect.

Tuberculous mediastinal lymphadenopathy presenting with left vocal cord palsy: A rare entity

A 23-year-old-male student, never-smoker presented to our hospital outpatient department with complaints of loss of appetite, unintentional weight loss, fatigue and low-grade fever for two months, hoarseness of voice (HOV) for two weeks. He was evaluated for HOV with video laryngoscopy which demonstrated left vocal cord palsy. Contrast enhanced CT Chest (CECT) was performed for evaluation of mediastinal lesions which revealed multiple peripheral enhancing conglomerate mediastinal lymph nodes. EBUS-trans bronchial needle aspiration (TBNA) and endobronchial biopsy were performed and specimens sent for smear and culture for AFB, Xpert MTB/RIF assay and histopathology. Results were consistent with Mycobacterium tuberculosis (MTB) infection and culture was positive for M. tuberculosis complex. Patient had been started on anti tubercular therapy (ATT) and during his 4th month follow up he showed clinicoradiological improvement without recovery of recurrent laryngeal nerve palsy.

GeneXpert in stool: Diagnostic yield in Intestinal Tuberculosis

BackgroundDiagnosing intestinal (Luminal) tuberculosis is challenging due to limited yield of diagnostic modalities like CT scan, colonoscopy with blind ileal biopsies. GeneXpert MTB/RIF (Xpert) assays for diagnosing tuberculosis have been performed in the body secretions with excellent results. Its yield in stool is tested in this study. ObjectiveThe study aims to evaluate the yield of GeneXpert assay in stool of suspected cases of intestinal tuberculosis. MethodsHundred patients with suspected intestinal tuberculosis underwent routine biochemical tests, radiological investigations, colonoscopy with caecal and blind ileal biopsies for histopathology. Fresh stool samples were collected, processed for DNA extraction, tested using 2:1 ratio of GeneXpert reagent to sample to give positive or negative results for Mycobacterium tuberculosis and Rifampicin resistance. ResultsOut of hundred participants, 52% were female. Mean age was 28.21 ± 12.13. CT scan and colonoscopy findings suggestive of TB were present in 47% and 43% participants respectively. GeneXpert in stool was positive in 20% cases. Considering mucosal biopsy with histopathology of intestinal specimens as diagnostic of abdominal Tuberculosis, sensitivity and specificity of GeneXpert was 39.1% and 85.7% respectively. ConclusionStool GeneXpert assay offers an alternative approach to detect intestinal tuberculosis rapidly with good diagnostic accuracy. Although it cannot replace the AFB culture and histopathology but contribute for early diagnosis and management.

TB PLEURAL EFFUSION WITH MODEST ELEVATION OF ADENOSINE DEAMINASE

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: Tuberculous pleural effusion (TBPE) occurs in 4% of all tuberculosis cases in the United States. Pleural fluid adenosine deaminase (pfADA) can help distinguish TBPE from other etiologies of pleural effusion. We present a case of TBPE with modest elevation of pfADA. CASE PRESENTATION: A 40 year old African American male with no past medical history, remote history of incarceration, presented with 4 days of fever and nonproductive cough. He denied any night sweats, chills or recent weight loss. Vitals on presentation: temperature 101.6○F, heart rate 115 bpm, blood pressure 129/84 mmHg, respiratory rate 20 breaths/min, pulse oximetry 96% on room air. On exam, he was tachypneic with left lower lung zone rhonchi. Initial investigations revealed leukocyte count of 8.2 (X10ˆ3/μL), elevated CRP at 129 mg/L and normal basic metabolic panel. A chest radiograph showed a large left pleural effusion. Vancomycin and levofloxacin were empirically initiated for suspected left sided pneumonia with parapneumonic effusion. Thoracentesis yielded 1800cc of clear yellow pleural fluid. Analysis revealed a lymphocyte-predominant exudate. (pH of 7.34, neutrophil count 3340, LDH 1551, Protein 4.8). CT of the chest on day 2 of admission demonstrated a new loculated inferior and lateral left base pleural fluid collection. Despite antibiotic therapy, patient continued to be febrile during days 3 and 4. Testing for influenza, HIV, Histoplasma, ANCA and ANA was negative. During a video-assisted thoracoscopy on Day 5, he was found to have fibrinous thick exudates indicating an early empyema with adhesions. Empyema was drained and decorticated, with complete re-expansion of the lung. Pathology of pleural biopsies revealed caseating granulomas indicative of tuberculosis. A quantiferon GOLD test returned positive. pfADA was mildly elevated at 20.5 units/L (normal: 0.0 – 9.4). He was started on treatment for presumptive pleural tuberculosis. Due to nonproductive nature of cough, patient underwent bronchoscopy for a BAL sample on Day 9, and subsequent AFB stain and culture was negative. He was discharged on INH, Rifampin and Pyrazinamide with vitamin B for 2 months, and continued on INH and Rifampin for a further 4 months. DISCUSSION: Measurement of pfADA may be useful to establish a presumptive diagnosis of TBPE relatively expeditiously when AFB stain and culture are negative. Based on several meta-analyses, pfADA levels >45 to 60 units/L is thought to be 97 percent specific for TBPE. Definitive diagnosis is often by the identification of M. Tuberculosis or necrotizing granulomas in pleural tissue or pleural fluid. In the presented case, despite a mildly elevated pfADA level, the diagnosis was clinched with histopathological evidence of tuberculous granulomas. CONCLUSIONS: While pfADA may have a supplementary role in the investigation of AFB-negative pleural effusion, pleural biopsy remains necessary for diagnosis of TBPE. Reference #1: 1. Klimiuk J1, Krenke R, Safianowska A, Korczynski P, Chazan R. 2015. Adv Exp Med Biol. 852:21-30. https://doi.org/10.1007/5584_2014_105 Reference #2: 2. Porcel JM. 2009. Tuberculous pleural effusion. Lung 187:263–270. https://doi.org/10.1007/s00408-009-9165-3. Reference #3: 3. Bays AM, Pierson DJ. Tuberculous Pleural effusion. Respiratory Care Oct 2012, 57 (10) 1682-1684; https://doi.org/10.4187/respcare.01443 DISCLOSURES: No relevant relationships by Dhruv Desai, source=Web Response No relevant relationships by Nikky Keer, source=Web Response No relevant relationships by Ngozika ORJIOKE, source=Web Response