Challenge Of Tuberculosis Research Articles

Phthisiology questions in International Congress of the European Respiratory Society 2019: achievement of the Ukrainian scientists

Abstract. The program of the International Congress of the European Respiratory Society (ERS) in 2019 covered the key topics of respiratory medicine. One of Congress’s leading issues has been tuberculosis, which is one of the world’s major threats to humanity. Since 1995, WHO has documented a TB epidemic in Ukraine and today this problem is urgent in our country.
 Aim. To analyze tuberculosis information at the 2019 ERS International Congress, with a summary of the phthisiology abstracts presented by Ukrainian scientists at this event.
 Materials and methods. The data regarding the abstracts of scientific reports were obtained from the Congress website and the online program of the personal account of an ERS member, doctor of medical sciences, professor Gumeniuk Galyna.
 Results. Tuberculosis issues were discussed daily in Congress in the form of symposia, expert meetings, thematic and poster discussions and oral presentations. In total, 201 short messages were addressed at the 2019 ERS Congress of Phthisiology, including 7 abstracts (3.5 %) owned by Ukrainian scientists.
 Conclusions. Ukrainian phthisiologists actively participated in the work of the Congress ERS 2019. Topics presented by national scientists reports (epidemiology, treatment of tuberculosis with drug resistance, including patients with HIV infection, predicting the effectiveness of treatment, prevention of adverse events and concomitant to tuberculosis disorders) meets the global challenges of tuberculosis in the world.

Tuberculosis treatment outcome and its associated factors among people living with HIV and AIDS in Fako Division of Cameroon.

BackgroundTuberculosis (TB) and HIV co-infection challenges treatment and worsens the outcome of TB treatment. This study aimed to assess the outcome of TB treatment and factors facilitating treatment success among people living with HIV/AIDS in Fako Division of the South West Region of Cameroon.MethodsA hospital-based retrospective cohort study was conducted by manually reviewing medical records of HIV/TB co-infected patients from January 2010 to September 2017. A structured data collection form was used to review the medical records of HIV patients co-infected with TB aged 10 years and older. Patients with incomplete files were dropped from the study. Treatment success was defined as the sum of patients who were declared cured and those who had completed treatment, as per the World Health Organization’s recommendations. Data were analyzed using Statistical Package for Social Sciences version 21. Bivariate and multivariate logistic regression model was carried out to identify factors facilitating successful TB treatment outcome. Significance was obtained through adjusted odds ratio with its 95% confidence interval and a p<0.05.ResultsA total of 2,986 files were reviewed but 2,928 (98.1%) were retained. Out of the 2,928 medical files of adult TB patients reviewed, 1,041 (35.6%, [95% CI 33.8%-37.3%]) were HIV/TB co-infected. The 1,041 co-infected patients had a mean age of 37.07 (SD of10.02) years and 56.3% were females. The treatment outcome of TB patients were 795(76.4%) cured, 23(2.2%) treatment completed, 99(9.5%) were lost to follow-up, 16 (1.5%) failed, 72(6.9%) died and 36(3.5%) transferred out. A successful treatment outcome was achieved in 818(78.6%,[95% CI: 76.0%–81.0%]) patients. Being a female [COR 1.61, 95% CI: 1.19–2.17, p = 0.002], receiving TB treatment in 2014 [COR 2.00, 95% CI: 1.11–3.60, p = 0.021] and 2015 [COR 2.50, 95% CI: 1.39–4.50, p = 0.002], having relapsed TB infection [COR 0.46, 95% CI: 0.23–0.93, p = 0.031], receiving ART [COR 1.95, 95% CI: 1.28–2.97, p = 0.002] and Cotrimoxazole [COR 2.03, 95% CI: 1.12–3.66, p = 0.019] were factors significantly associated with successful treatment. After adjusting for confounders, successful treatment outcome were associated with being a female [AOR 1.6; 95% CI: 1.21–2.22, p = 0.001], diagnosis of TB in 2014 [AOR 1.90; 95% CI: 1.04–3.45, p = 0.036] and 2015 [AOR 2.43; 95% CI: 1.33–4.43, p = 0.004].ConclusionThere is a high TB treatment success rate among HIV/TB co-infected patients in our setting, although below the target set by the WHO. Specific interventions aimed at enhancing patient outcomes are recommended.

Challenges in urogenital tuberculosis.

For better understanding of urogenital tuberculosis (UGTB), its clinical spectrum and characteristic features need to be evaluated. One hundred and forty-two cases of UGTB patients were analyzed retrospectively. We considered age, gender, symptoms, and diagnostic procedures. The total of 142 patients were divided into group A (consisted of 93 patients with only urinary TB), group B (consisted of 13 male patients with generalized UGTB, including urinary TB and male genital TB (MGTB). Group C consisted of 36 patients with MGTB. Sixty patients in groups A and B 56.6% had kidney TB third-to-fourth stages, which are incurable for anti-TB therapy and require surgery. The urinary tract was involved in 48 patients (45.3%): 25 (23.6%) had ureteral TB and 23 (21.7%) had also bladder TB. The most common symptom for kidney TB was flank pain (69.8%) followed by dysuria (47.2%). Perineal pain and dysuria were most common symptoms for prostate TB and were found in 87.5% (14 patients) and 56.3% (9 patients), respectively. Of total, in only 58 UGTB patients (40.8%), the culture for Mycobacterium tuberculosis (Mtb) was positive. Of 142 patients with UGTB, 106 (74.7%) had kidney TB and 13 (9.2%) of them had kidney TB in combination with MGTB. Only MGTB (prostate, scrotal, or generalized) was diagnosed in 49 (34.5%) patients. The most common symptoms were flank pain and dysuria. Identification of Mtb in UGTB is difficult. Therefore, the most advanced microbiological technology should be used to establish the correct diagnosis.

Efficacy and tolerability of desensitization in the treatment of delayed drug hypersensitivities to anti-tuberculosis medications.

Delayed drug hypersensitivity to first-line anti-tuberculosis medication is a major challenge in tuberculosis treatment. This study was performed to investigate the efficacy/tolerability of desensitization therapy in treatment of first-line anti-tuberculosis medication hypersensitivity and the usefulness of immunologic evaluation therein. This study was conducted as a prospective, observational cohort study. Subjects who experienced hypersensitivity reactions, including maculopapular exanthema (MPE) and drug reaction with eosinophilia and systemic symptoms (DRESS), to first-line anti-tuberculosis medications (isoniazid [INH], ethambutol [EMB], rifampin [RFP], and pyrazinamide [PZA]) were enrolled. Patch, intradermal, lymphocyte transformation, and oral provocation tests were performed to determine culprit drugs, which were desensitized with rapid and graded challenge protocols. Breakthrough reactions (BTRs) during or after desensitization were assessed. In total, 31 desensitization treatments (INH, 8; EMB, 8; RFP, 11; PZA, 4) to 12 patients (8 with MPE and 4 with DRESS) were performed. The overall success rate of desensitization was 80.7%. All the study subjects except one completed the full course of anti-tuberculosis treatment. The overall BTR free rate was 64.5%. Sixteen (80%) treatments for MPE and four (36.4%) for DRESS were BTR free (P = 0.023). Drugs that were positive on any two of three immunologic studies showed significantly high BTR rates (P = 0.014), although this was not correlated with desensitization failure rate. Rapid desensitization therapy to multiple anti-tuberculosis medications for delayed drug hypersensitivity was safe and successful. Combination of multiple immunologic evaluations may predict BTR although it needs validation in larger studies.

Enduring Challenge of Latent Tuberculosis in Older Nursing Home Residents: A Brief Review.

Tuberculosis (TB) kills almost 4,000 people a day and is competing with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) as the most deadly infectious disease in the world. The gold standards of detection and management of latent tuberculosis infection (LTBI) have not been successful in complete eradication of the disease. Current screening modalities of TB include tuberculin skin testing (TST) and/or interferon-γ release assay (IGRA). However, these screening tests have been heavily studied in healthy populations but not in the elderly who are more likely to have multiple risk factors for progression to active TB from LTBI. The largest population that is harboring LTBI is the elderly, specifically those residing in nursing homes. Yet, unfortunately, guidelines for standards of detection and treatment for this specific group are lacking. In this review, we look at TST versus IGRA screening for LTBI in the elderly living in nursing homes. We review a cross-sectional study done at Staten Island University Hospital, and several other assessments of the sensitivity and accuracy of both screening tools. Furthermore, this review looks at the appropriateness of current LTBI treatment and prophylaxis in elderly patients residing in close quarters. The reviews point to the superiority of IGRA testing in the elderly for screening LTBI. The IGRA has been shown to be more sensitive to the detection of LTBI than TST. Additionally, medical complexities that the elderly population possesses may present challenges and resistance to standard treatments of LTBI. It is recommended via the literature that the addition of vitamin D, or alternative therapies (e.g. rifampin) could produce better outcomes for elderly patients with LTBI than the current 9 months of isoniazid (INH). As the older adults represent the fastest growing segment of our population and the largest LTBI reservoir in the USA, revisiting screening and treatment of LTBI in the elderly living in nursing homes may prove to lead to a path of TB eradication once and for all.

Whole genome sequencing data of 1110 Mycobacterium tuberculosis isolates identifies insertions and deletions associated with drug resistance

BackgroundDrug resistance in Mycobacterium tuberculosis (MTB) is one of the major challenges in tuberculosis (TB) treatment. However, known mutations cannot explain all of the cases of resistance and little research has focused on the relationship between insertions / deletions (indels) and drug resistance.ResultsHere, we retrieved whole genome sequencing data of 743 drug-resistant MTB strains and 367 pan-susceptible strains from TB patients from the public domain to identify novel genomic markers of drug resistance. A total of 20 region markers containing genes and intergenic regions (IGRs) with significant statistical correlation with antibiotic resistance were revealed, four of which have been previously reported to be associated with drug resistance. In addition, 83 point markers containing frameshift (FS) mutations and IGR indels were also identified independently based on differences in their incidence rates between drug-sensitive and -resistant strains. Among the 83 point markers, eight indels were detected in known drug-associated genes or IGRs. Furthermore, the overlap between 20 region markers and 83 point markers further indicated their associations with drug resistance. The markers identified were involved in essential bacterial metabolic functions, including cell wall and transmembrane transporter functions. A strong correlation between FS mutations and mutations in DNA repair genes including I21V in alkA, R48G in mutT4 and P2R in nth was also found.ConclusionsThis study identified a set of novel genetic markers with FS mutations and IGR indels associated with MTB drug resistance, which greatly broadens the pool of mutations related to MTB drug resistance. This insight may be important in identifying novel mechanisms of drug resistance in MTB.

A study on reasons for nonadherence to 99DOTS among HIV-tuberculosis coinfected patients in Davanagere district, Karnataka

Background: Ensuring the patient’s adherence is the critical challenge in tuberculosis (TB) treatment. To monitor the adherence to anti-TB drugs in HIV-TB coinfected patients, 99 directly observed treatment short (99DOTS) course has been introduced. Objectives: The objectives of the study were to know the reasons for nonadherence to 99DOTS among HIV-TB coinfected patients. Materials and Methods: A community-based cross-sectional study was conducted among 85 HIV-TB coinfected patients on 99DOTS in Davanagere district. A pretested semi-structured questionnaire was used to collect the data from October to December 2016. Data were analyzed using SPSS software v16.0. Descriptive statistics such as frequency and percentage were calculated. Results: Of 85 study subjects, 81 (95%) of them were found to be nonadherent. Multiple factors were reasons for nonadherence, i.e. did not take TB medication (53%), not aware that they should call daily (35%), do not know how to use mobile phone (30%), network problem and mobile issues (20%), and used to call from any of the unregistered phone numbers (17%). Forgot to call after taking medication (6%) and registered phone number was of neighbors/relatives (5%). Reasons for not taking the medications were forgot to take medications (26%), discontinued because of too many pills (11%), avoid the side effects (9%), improvement in health (7%), alcohol intake (6%), due to other illness (6%), and stigma at home (3%). Conclusions: HIV-TB coinfected patients on 99DOTS were found to be nonadherent because of multiple reasons. Orientation regarding the importance of adherence to drugs and calling daily after medication only from a registered number is required before initiation of treatment.

The burden and challenges of tuberculosis in China: findings from the Global Burden of Disease Study 2015

To achieve the End Tuberculosis (TB) Strategy, it is important to understand the characteristics of TB in China, which may provide the government with important clues for controlling TB by 2030. Data from the Global Burden of Disease Study 2015 (GBD 2015) and Institute for Health Metrics and Evaluation (IHME) were reviewed and analysed. The age-standardized death rate decreased by 83.79% [95% uncertainty interval (UI) 73.06–87.10] from 1990 to 2015. The age-standardized prevalence of TB in males decreased steadily by 33.88% (95% UI 29.35–37.67) but nearly increased by 6.24% (95% UI -2.02–15.07) in females from 1990 to 2015. Disability-adjusted life years (DALYs) were higher in males than in females, and the highest TB burden was found in the elderly (70+ years of age). Over the period 1990–2015, the attributable age-standardized DALY rates for smoking decreased by 12.98% (95% UI 2.40–24.27), but increased for alcohol use and high fasting plasma glucose (HFPG). Greater attention should be paid to females especially in the under 5 years of age group, and more latent reasons explaining TB DALYs should be explored in future studies.

Addressing the Challenges of Tuberculosis: A Brief Historical Account.

Tuberculosis (TB) is a highly contagious disease that still poses a threat to human health. Mycobacterium tuberculosis (MTB), the pathogen responsible for TB, uses diverse ways in order to survive in a variety of host lesions and to subsequently evade immune surveillance; as a result, fighting TB and its associated multidrug resistance has been an ongoing challenge. The aim of this review article is to summarize the historical sequence of drug development and use in the fight against TB, with a particular emphasis on the decades between World War II and the dawn of the twenty first century (2000).

Diagnostic Performance of Polymerase Chain Reaction Targeting Insertion Sequence (IS6110) for the Detection of Extra Pulmonary Tuberculosis

Background: The diagnostic challenges in extra-pulmonary tuberculosis remain to be addressed even though remarkable progress has been made in the diagnostics of pulmonary tuberculosis during the last decade. Methods: This study was conducted to evaluate the use of polymerase chain reaction (PCR) in diagnosis of definitive extra pulmonary tuberculosis patients, and to assess the performance of insertion sequence (IS)6110 based PCR assay as compared to conventional liquid culture by Microbial growth Indicator Tube (MGIT) 960 system. Results: A total of 792 clinical specimens were collected from clinically suspected extra pulmonary tuberculosis patients. The specimens included 22 ascitic fluids, 69 pleural fluids, 240 Cerebrospinal fluids (CSF), 386 endometrial tissues, 47 lymph nodes, 22 pus, one synovial fluid, one fallopian tube, two brain abscess and two ovarian cyst samples. All these clinical samples were subjected to Auromine O staining (FM) for acid fast bacilli (AFB) and culture on MGIT 960 tubes containing Modified Middlebrooks 7H9 broth medium. PCR was performed by targeting 123bp fragment of insertion sequence IS6110 of Mycobacterium tuberculosis. Our study of 792 specimens, revealed their 87.5% sensitivity to endometrial samples, 92.31% sensitivity for cerebrospinal fluid, and 66.66% sensitivity in Pleural fluid and 60% sensitivity in Lymph node samples. The combined sensitivity and specificity of the PCR IS6110 was calculated to be 85.71% and 82.91%, respectively. Conclusion: PCR using IS6110 primer was able to pick up more positivity in extra pulmonary samples as compared to conventional culture method for the detection of M. tuberculosis.

Preservation of sputum samples with cetylpyridinium chloride (CPC) for tuberculosis cultures and Xpert MTB/RIF in a low-income country

BackgroundCulture contamination with environmental bacteria is a major challenge in tuberculosis (TB) laboratories in hot and humid climate zones. We studied the effect of cetylpyridinium chloride (CPC) preservation on culture results and performance of Xpert MTB/RIF.MethodsConsecutive sputum samples from microscopy smear-positive TB patients were collected. Two-hundred samples were equally split in two aliquots, one aliquot was treated with CPC and stored at ambient temperature for 7 days. The second aliquot was immediately processed. Samples were decontaminated for 20, 15 or 10 min, and subsequently cultured on Löwenstein-Jensen medium. Furthermore, 50 samples were stored for 7, 14 and 21 days, and 100 CPC-pretreated samples tested by Xpert MTB/RIF.ResultsCPC pretreated samples showed a higher culture yield compared to non-treated sputum samples across all decontamination times: 94% vs. 73% at 10 min (p = 0.01), 94% vs. 64% at 15 min (p = 0.004), and 90% vs. 52% at 20 min (p < 0.001). The quantitative culture grading was consistently higher in CPC treated compared to non-CPC treated samples. The proportion of contaminated cultures was lower in CPC pretreated samples across all decontamination times (range 2-6%) compared to non-CPC treated samples (15-16%). For storage times of CPC treated samples of 7, 14, and 21 days, 84, 86, and 84% of the respective cultures were positive. Of 91 CPC treated samples with a positive culture, 90 were also Xpert MTB/RIF positive.ConclusionsCPC increases culture yield, decreases the proportion of contamination, and does not alter the performance of Xpert MTB/RIF.

The Global Fund in China: Multidrug-resistant tuberculosis nationwide programmatic scale-up and challenges to transition to full country ownership.

China has the world’s second largest burden of multidrug-resistant tuberculosis (MDR-TB; resistance to at least isoniazid and rifampicin), with an estimated 57,000 cases (range, 48,000–67,000) among notified pulmonary TB patients in 2015. During October 1, 2006–June 30, 2014, China expanded MDR-TB care through a partnership with the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). We analyzed data on site expansion, patient enrolment, treatment outcomes, cost per patient, and overall programme expenditure. China expanded MDR-TB diagnostic and treatment services from 2 prefectures in 2006 to 92 prefectures, covering 921 of the country’s 3,000 counties by June 2014. A total of 130,910 patients were tested for MDR-TB, resulting in 13,744 laboratory-confirmed cases, and 9,183 patients started on MDR-TB treatment. Treatment success was 48.4% (2011 cohort). The partnership between China and the Global Fund resulted in enormous gains. However, changes to health system TB delivery and financing coincided with the completion of the Global Fund Programme, and could potentially impact TB and MDR-TB control. Transition to full country financial ownership is proving difficult, with a decline in enrollment and insufficient financial coverage. Given needed improvement to the current treatment success rates, these factors jeopardise investments made for MDR-TB control and care. China now has a chance to cement its status in TB control by strengthening future financing and ensuring ongoing commitment to quality service delivery.

Novel nanoparticle delivery systems for rifampicin: an effective strategy against tuberculosis?

Novel nanoparticle delivery systems for rifampicin: an effective strategy against tuberculosis?

Tuberculosis control programs and challenges in developed cities with intermediate disease burden: China experience.

Tuberculosis (TB) remains one of the world’s deadliest infectious disease (1). Historically, it not only posed threats in developing countries, but also affected population in the developed world. From a global perspective, more guidance and focus were prioritized in low-income countries and rural areas due to their high TB burdens. Recently, the World Health Organization (WHO) proposed the End TB Strategy targets (90% reduction in TB incidence and 95% reduction in TB deaths by 2035) and the action framework in low-incidence countries (1,2). However, how to strive for TB elimination in urban areas with intermediate disease burden is still not well understood.

Association of CYP2B6 gene polymorphisms and anti-tuberculosis drug-induced hepatotoxicity in a Chinese population

ObjectivesAntituberculosis drug-induced hepatotoxicity (ATDH) remains a common and severe challenge in tuberculosis (TB) chemotherapy. A growing number of studies have revealed that genetic polymorphisms affect an individual's susceptibility to ATDH. The aim of this study was to explore the role of cytochrome P450 family 2 subfamily B member 6 (CYP2B6) gene polymorphisms in the development of ATDH in Chinese TB patients. MethodsCYP2B6*6 genotypes were determined in TB patients with and without ATDH. Association between polymorphisms and risk of ATDH was estimated by multiple logistic regression analysis. ResultsA total of 343 eligible TB patients (166 with ATDH; 177 without ATDH) were included in this study. Analysis of all subjects revealed no statistical differences in genotype distribution between the two groups. However, the CYP2B6 *6/*6 genotype was significantly associated with decreased risk of ATDH in the male subgroup (P=0.039, OR=0.097, 95% CI: 0.011–0.885). Furthermore, in male patients, the presence of the CYP2B6*6 allele was significantly higher in the non-ATDH group compared with the ATDH group (26.2% vs. 15.5%, P=0.020, OR=0.522, 95% CI: 0.301–0.903). ConclusionsThis study is the first to demonstrate an association between CYP2B6 polymorphisms and the risk of ATDH in the Chinese population. We have shown that males who have the CYP2B6 *6/*6 genotype may be less susceptible to the development of ATDH. Further studies are required to confirm this genetic association result.

Tuberculosis in HIV-infected South African children with complicated severe acute malnutrition.

Academic tertiary referral hospital in Durban, South Africa. To describe the incidence and diagnostic challenges of tuberculosis (TB) in human immunodeficiency virus (HIV) infected children with severe acute malnutrition (SAM). Post-hoc analysis of a randomised controlled trial that enrolled antiretroviral therapy naïve, HIV-infected children with SAM. Trial records and hospital laboratory results were explored for clinical diagnoses and bacteriologically confirmed cases of TB. Negative binomial regression was used to explore associations with confirmed cases of TB, excluding cases where the clinical diagnosis was not supported by microbiological confirmation. Of 82 children enrolled in the study, 21 (25.6%) were diagnosed with TB, with bacteriological confirmation in 8 cases. Sputum sampling (as opposed to gastric washings) was associated with an increased risk of subsequent diagnosis of TB (adjusted relative risk [aRR] 1.134, 95%CI 1.02-1.26). Culture-proven bacterial infection during admission was associated with a reduced risk of TB (aRR 0.856, 95%CI 0.748-0.979), which may reflect false-negative microbiological tests secondary to empiric broad-spectrum antibiotics. TB is common in HIV-infected children with SAM. While microbiological confirmation of the diagnosis is feasible, empiric treatment remains common, possibly influenced by suboptimal testing and false-negative TB diagnostics. Rigorous microbiological TB investigation should be integrated into the programmatic management of HIV and SAM.

Diagnosis challenges of peritoneal tuberculosis in immunocompetent patients: case report and short-review of the literature

Diagnosis challenges of peritoneal tuberculosis in immunocompetent patients: case report and short-review of the literature

Tuberculosis elimination and the challenge of latent tuberculosis

Latent tuberculosis infection (LTBI) affects one third to one fourth of the human population and is the reservoir for a significant proportion of emerging active tuberculosis (TB) cases, especially in low incidence countries. The World Health Organization launched in 2015 the END-TB strategy that aims at TB elimination and promotes, for the first time ever, the management of LTBI. The preventive package, basically consisting of testing and treatment for LTBI in groups at high risk of reactivation, is a mainstay of the first pillar of the strategy, alongside prompt diagnosis and early treatment of both drug-susceptible and drug-resistant TB disease. Testing and treatment for LTBI should be pursued with a programmatic perspective. This implies strong political commitment, adequate funding and an effective monitoring and evaluation system. People living with HIV and children under five years of age who are household contact of a contagious TB cases are primarily targeted in all epidemiological setting. In high resource and low incidence setting, additional at risk populations should also be the target for systematic LTBI testing and treatment. Research is urgently needed to develop diagnostic tests with higher predictive value to identify individuals that progress from infection to disease. Similarly, shorter and safer treatment regimens are needed to make the trade-off between potential benefits and harms more favourable for an increasing proportion of infected individuals.

Challenges of Tuberculosis in Iran

Background: Despite the implementation of the national control program, tuberculosis is one of the greatest health problems in Iran. The prevalence of different strains in specific ethnic populations suggests that Mycobacterium tuberculosis transmission has been limited and restricted to close contact. Objectives: In the present review, we describe the epidemiology of tuberculosis in Iran. Methods: In this review article, databases including Scopus, PubMed, and Google scholar were used to search for the epidemiology of tuberculosis in Iran. Results: Since 1996, tuberculosis incidence has been decreased as the national tuberculosis control program was established in Iran. However, due to the emergence of drug-resistant strains, recurrence of the disease, and association of tuberculosis with HIV pandemic, tuberculosis is becoming a health problem in Iran like many other parts of the world. Moreover, several other factors such as poverty, homelessness, inadequate access to health services, and lack of infrastructure in public health play an important role in worsening the situation. The distribution of the disease is not similar in all parts of Iran and it is higher in the western and eastern parts than the central areas. Conclusions: Review of the studies revealed that levels of multidrug-resistant tuberculosis among new tuberculosis patients are increasing in Iran and the vaccination system needs to be reformed. Because of the increasing number of patients coming from neighboring countries with multidrug-resistant tuberculosis, this area needs more stewardship and control in order to prevent the outbreak of multidrug-resistant tuberculosis. Finally, by improving the healthcare system, it is trusted that a more noteworthy number of these patients will be cured in Iran.

Pseudotumoral Abdominal Tuberculosis in Immunocompetent Adults: Report of Three Cases and Review of the Literature

Purpose: To highlight diagnostic challenges of pseudotumoral abdominal tuberculosis. Materials and methods: Three cases of pseudotumoral abdominal tuberculosis were compiled in our department between 2014 and 2015. They were aged 34 years, 42 years and 61 years respectively. They were immunocompetent and had no personal or family history of tuberculosis. Clinical presentations were non-specific, represented by abdominal pain and weight loss in the three patients and chronic diarrhea in one patient. Abdominal ultrasound and computed tomography CT were performed in all patients. Abdominal MRI was performed in one case as well as a colonoscopy. Results: Retroperitoneal tuberculosis and colic tuberculosis were noted in the 1st and 2nd case. Macro-nodular and biliary hepatic tuberculosis was retained in the third case. The diagnosis was based upon histopathology in the 3 cases showing tubercular granuloma with caseation. Anti-tuberculosis therapy was prescribed for 6 months. Evolution was favorable in all patients. Conclusion: Tuberculosis continues to present diagnostic difficulties, particularly in its pseudo-tumoral form, even in endemic tuberculosis countries like ours.