Diagnosis Of Extrapulmonary Tuberculosis Research Articles

Xpert® MTB/RIF assay on formalin-fixed paraffin-embedded tissues in the diagnosis of extrapulmonary tuberculosis.

BackgroundDiagnosis of extrapulmonary tuberculosis continues to be a challenge due to the complexity of the causative organism and the wide array of pathologic features seen in this infection. Xpert MTB/RIF can be used on fresh or frozen tissue specimens for diagnosis of tuberculosis with good results. However, there is little data on its use with formalin-fixed paraffin-embedded (FFPE) tissues.ObjectivesThe aim of this study was to demonstrate the potential utility of Xpert MTB/RIF and to compare its performance to Ziehl-Neelsen staining for the detection of Mycobacterium tuberculosis from FFPE tissues using histological features from haematoxylin and eosin staining as the gold standard.MethodsEighty randomly selected archival FFPE tissues exhibiting histological features of tuberculosis were included in the study. After deparaffinisation and lysis, all the tissue specimens were subjected to the Xpert® MTB/RIF assay. The outcome measures were proportions of positively identified cases by each test.ResultsUsing histology as the gold standard, the sensitivity of Ziehl-Neelsen staining was 20.3% (95% confidence interval: 12% – 30.8%), and the sensitivity of the Xpert® MTB/RIF assay was 53.2% (95% confidence interval: 41.6% – 64.9%); the difference was statistically significant (p = 0.002). None of the cases tested positive for rifampicin resistance.ConclusionWith prior deparaffinisation and lysis, FFPE tissues are amenable to testing by Xpert® MTB/RIF assay. A validation study to determine the clinical utility, analytical optimisation and cost implications of this assay for FFPE tissues is recommended.

Comparative Study of Pulmonary and Extra-Pulmonary Tuberculosis in Bhutan (2015-2017)

Introduction: Extrapulmonary Tuberculosis (EPTB) has been increasingly diagnosed and reported compared to Pulmonary TB (PTB) in Bhutan in the recent years. In this comparative study, our study describes the epidemiology, diagnostic modalities used, inconsistency in case-classification and treatment outcomes of PTB and EPTB cases diagnosed from 2015-2017.
 Methods: A retrospective descriptive study was conducted by retrieving patient records maintained at the 11 TB Reporting Centres. Using two stage cluster sampling technique, nine primary sampling units (9-PSUs) were generated for the years 2015, 2016 and 2017 respectively. Based on the highest caseloads among 32 TB Reporting Centres, nine primary clusters were selected first and final sample of 350 for each year were drawn using systematic random sampling technique from the PSUs.
 Results: We recruited a total of 1048 cases (PTB=555, EPTB=493) in the final descriptive analysis. The median age of the subjects was 27 years (range 1-87) with slight female predominance (53%). Students were the highest (23.85%) followed by farmers (17.94%). The proportion of PTB was (52.95%), EPTB of (47.08%) and clinically diagnosed EPTB accounted for (92%), which is extremely high. Twelve miliary/disseminated TB cases (1.15%) were miss-classified as EPTB and (56%) EPTB cases were not classified based on the body sites involved. The overall treatment success rate (TSR) of PTB and EPTB was (93.26%).
 Conclusion: We recommend an expert team to revisit National TB treatment guidelines on diagnosis of EPTB and ensure EPTB site/s are properly identified and documented. Sensitize clinicians and other units (ENT, Surgery, Orthopedics, MCH, General OPD etc.) on the referral of EPTB cases to Medical Specialist/Chest Physician for consultation.

Splenic abscess as a rare symptom of the extrapulmonary tuberculosis – case report

Introduction: Extrapulmonary tuberculosis can involve any organ or tissue. It is a rare disease in the Czech Republic with an incidence rate of 0.62 cases per 100.000 persons. It affects mostly immunocompromised patients. The most common sites include lymph nodes, the urogenital system, skin, joints, bones and serous epithelium – the peritoneum, pleura, and pericardium. Splenic involvement is rare. Mycobacterium is a slow growing intracellular parasite. The diagnostic process is very difficult; microbiological diagnosis is critical. Case report: An 84 years old female patient with subcapsular splenic rupture with no trauma history as a cause of anemia. Splenic abscess was diagnosed during surgical revision and splenectomy. Tuberculosis was suspected based on subsequent histological analysis, which was confirmed after nine weeks of peritoneal fluid culture. The surgical procedure and postoperative hospitalization were not associated with any complications. The patient was referred to the respiratory clinic for further treatment. Conclusion: The diagnosis of extrapulmonary tuberculosis including splenic localization should always be considered. A sample from the affected tissue or effusion must be collected in the case of unclear perioperative findings and sent for complete bacteriological testing, including mycobacterial culture. If a tuberculous splenic abscess is found, the therapeutic process should involve its complete drainage in combination with long-term anti-TB medication.

Clinical Manifestations and Diagnosis of Extrapulmonary Tuberculosis in Children

Clinical Manifestations and Diagnosis of Extrapulmonary Tuberculosis in Children

Akciğer Dışı Tüberkülozu Olan Çocuklarda Klinik Bulgular ve Tanı

Akciğer Dışı Tüberkülozu Olan Çocuklarda Klinik Bulgular ve Tanı

The ratio of tuberculosis-specific antigen to phytohemagglutinin in T-SPOT assay in the diagnosis of active tuberculosis

Objective: The aim of this study was to determine the performance of the ratio of tuberculosis-specific antigen (TBAg) to phytohemagglutinin (PHA) (TBAg/PHA ratio) in T-SPOT assay in the diagnosis of active tuberculosis (ATB). Methods: Between January 2014 and January 2017, 378 Mycobacterium tuberculosis (MTB) culture positive patients (268 cases of pulmonary tuberculosis, 110 extra-pulmonary tuberculosis) and 824 healthy individuals were recruited from Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. T-SPOT assay was performed and TBAg/PHA ratio was calculated in all the participants. To validate the study, another group of 223 MTB culture positive TB patients with positive T-SPOT results were recruited from Guangzhou Chest Hospital between January 2017 and December 2017. This was a retrospective case-control study and differences between groups were analyzed using the Mann-Whitney U-test. Results: Of the 378 culture positive ATB patients, 344 patients had positive T-SPOT results. Of the 824 healthy individuals, 204 individuals had positive T-SPOT results. Using healthy individuals as the control group, the sensitivity and specificity of T-SPOT assay in the diagnosis of ATB were 91.0% (344/378) and 75.2% (620/824). Directly using T-SPOT results had a limited accuracy in distinguishing ATB from latent tuberculosis infection (LTBI). The area under the receiver operating characteristic (ROC) curve was between 0.7 and 0.8. However, a further calculation of the TBAg/PHA ratio showed a better performance than TBAg in distinguishing these two conditions, and the area under the ROC curve was 0.881 (95% CI: 0.853-0.909). If using the threshold value of 0.234, the sensitivity and specificity of the TBAg/PHA ratio in distinguishing ATB from LTBI were 69.5% (239/344) and 94.12% (192/204). The validation data showed that the performance of the TBAg/PHA ratio in distinguishing ATB from LTBI was also satisfactory, and the area under the ROC curve was 0.901 (95% CI: 0.872-0.931). Furthermore, the TBAg/PHA ratio had an important role in the diagnosis of extra-pulmonary tuberculosis. If using the threshold value of 0.234, the sensitivity and specificity of the TBAg/PHA ratio in the diagnosis of extra-pulmonary tuberculosis were 79.2% (76/96) and 94.1% (192/204). The area under the ROC curve was 0.932 (95% CI: 0.897-0.967). Conclusions: The TBAg/PHA ratio in T-SPOT assay was better than directly using T-SPOT results in distinguishing ATB from LTBI. This ratio also showed a potential use in the diagnosis of extra-pulmonary tuberculosis.

PO 8168 CLINICAL UTILITY OF XPERT MTB/RIF ASSAY FOR THE DIAGNOSIS OF EXTRAPULMONARY TUBERCULOSIS IN ETHIOPIA

BackgroundThe diagnosis of extrapulmonary tuberculosis (EPTB) is often made on clinical suspicion alone, and many people receive the wrong diagnosis leading to unnecessary TB treatment or poor outcomes from untreated EPTB. In this study, we evaluated the clinical utility of the Xpert MTB/RIF assay on routinely collected extra-pulmonary specimens in Ethiopia.MethodsThis study was carried out at Jimma University Specialized Hospital, Southwest Ethiopia from September 2015 to June 2017. Extra-pulmonary specimens were collected from 572 patients clinically suspected of suffering from EPTB. All specimens were tested for TB by smear-microscopy, culture and Xpert MTB/RIF. The diagnostic accuracy of Xpert MTB/RIF was calculated compared to a composite reference standard (CRS), composed of liquid culture and anti-TB treatment response.ResultsIn total, 572 extra-pulmonary specimens (279 lymph node, 159 pleural, 80 peritoneal, 45 cerebrospinal and 9 pericardial fluids) were tested. The pooled sensitivity and specificity of Xpert MTB/RIF were calculated to be 91% and 90.6% respectively when compared to culture. The pooled sensitivity of Xpert MTB/RIF was decreased to 75% and the specificity was improved to 98% when Xpert MTB/RIF was compared to the CRS. The sensitivities among the specimen types differed markedly. The highest sensitivity was documented for lymph node (90%), moderate sensitivity for cerebrospinal (53%), while the sensitivity was lowest for pleural (30%) and peritoneal (32%) fluids. Xpert MTB/RIF, in addition, detected rifampicin resistance in 13 patients in perfect agreement with line probe assay.ConclusionOur study showed that Xpert MTB/RIF is likely to be of greatest utility when testing lymph node specimens. A negative Xpert MTB/RIF result on fluid specimens does not exclude the diagnosis of EPTB and patients with a high clinical probability of EPTB should be started on anti-TB treatment.

Assessment of the Xpert MTB/RIF Ultra assay on rapid diagnosis of extrapulmonary tuberculosis

ObjectiveTo evaluate the diagnostic performance of Xpert MTB/RIF Ultra for EPTB (Extrapulmonary Tuberculosis) patients on different types of extrapulmonary specimens from different anatomic sites. MethodsPatients with suspected EPTB were prospectively included, extrapulmonary specimens were collected and subjected to culture, Xpert and Xpert Ultra assays in accordance with relevant guidelines. ResultsA total of 225 cases were included which contained 200 EPTB cases (43 culture-positive EPTB, 157 culture-negative EPTB which were diagnosed based on pathological results and a satisfied response to anti-TB treatment) and 25 non-EPTB cases. Sensitivities of Xpert Ultra and Xpert for culture-positive cases were 83.7% (95%CI, 68.7–92.7) and 67.4% (95% CI, 51.3–80.5) respectively. Specificities of Xpert Ultra and Xpert were 92.0% (95% CI, 72.5–98.6) and 96.0% (95% CI, 77.7–99.8) respectively. The sensitivities of Xpert Ultra, Xpert and culture for 200 EPTB cases were 52.5% (105/200, 95% CI, 45.4–59.6), 34.0% (68/200, 95% CI, 27.6–41.1) and 21.5% (43/200, 95% CI, 16.2–28.0) respectively. By comparison among different types of specimens, Xpert Ultra can detect 78.9% (56/71) of EPTB on fine-needle aspiration (FNA) tissues which was higher than that on pleural fluid (43.7% (45/103), p<0.05. ConclusionsXpert Ultra assay had a higher sensitivity than those of Xpert and culture on extrapulmonary specimens, which could be a promising approach for rapid EPTB diagnosis.

Diagnostic accuracy of loop-mediated isothermal amplification assay for extra-pulmonary tuberculosis in Indian population

BackgroundConfirmatory diagnosis of extra-pulmonary tuberculosis remains a true challenge owing to difficulty in procuring appropriate specimen, inefficient laboratory methods and paucibacillary nature of infection. These obstructions become all the very difficult in pediatric EPTB cases, due to non-specific clinical signs and symptoms, low sensitivity of smear microscopy and culture, lack of awareness among clinicians, etc. Aim of the studyThe present study aimed to evaluate the diagnostic accuracy of rapid and cost-effective loop-mediated isothermal amplification (LAMP) assay for EPTB diagnosis in children. MethodsA total of 154 cases were analyzed by EPTB-site smear microscopy, culture, PCRs for IS6110, MPB64 & Pab genes, nested PCR and LAMP assay. Single-gene PCRs were performed by custom-synthesized primers. Nested PCR was performed using the 3B BIOTUB Kit and the LAMP assay was done using the Nu-LAMP TB kit. ResultsWe observed that the molecular tests displayed 4-fold higher positivity rate (minimum 46%) in comparison to the microbiological tests (maximum 11.03%). In contrast to the composite reference standard, LAMP assay was found to be 79.6% sensitive and 78% specific for EPTB diagnosis in childhood cases. ConclusionsOur results indicate that LAMP assay is a promising technique for efficient diagnosis of EPTB in children belonging to resource-limited regions.

To Assess Diagnostic value of Lymphocyte // Neutrophil ratio and Adenosine Deaminase in the Diagnosis of Exudative Tubercular Pleural Effusion

Background: Adenosine deaminase (ADA) is considered a valuable tool in the diagnosis of extra pulmonary tuberculosis. Objective: To evaluate the role of ADA and L/N ratio in the diagnosis of tuberculous pleural effusion in patients with exudative pleural effusion and to analyze the cause of non tuberculous exudative pleural effusion. Methods: This hospital based prospective study was conducted from November 2017 to November 2018 with a total number of 100 patients of exudative pleural effusion who were admitted in medical wards of Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, India. Patients with transudative pleural effusion, age less than 12years and those who were hemodynamically unstable were excluded from the study. Results: A total of 100 patients with exudative pleural effusion were analyzed, of which 69 were males and 31 females. maximum number of cases were seen in age group between 21 and 40 yrs. Total ADA was found to be >40U/L in all cases of TB effusion. All cases of TB effusion were lymphocyte predominant with L/N ratio > 0.75. In case of exudative pleural effusion due to non tuberculous etiology L/N ratio was < 0.75. Conclusion: 100 cases of exudative pleural effusion were analyzed based on Total ADA and L/N ratio. 80 cases were due to tuberculosis. ADA value of >100 U/L was observed only in tuberculous effusion. L/N ratio was >0.75 in 80 cases of TB effusion and in none of the non tuberculous effusion. Combined use of ADA and L/N ratio is more efficient means for diagnosing tubercular pleural effusion than the use of ADA alone.

Evaluation of cases of pediatric extrapulmonary tuberculosis: a single center experience.

Aim:Extrapulmonary tuberculosis is observed more frequently and leads to complications with a higher rate in children compared with adults because the risk of lymphohematogen spread is higher. In this study, the clinical, laboratory, and radiologic findings and treatment outcomes were evaluated in pediatric patients who were followed up in our clinic with a diagnosis of extrapulmonary tuberculosis.Material and Methods:Seventy patients aged 0–18 years who were followed up with a diagnosis of extrapulmonary tuberculosis between 2008 and 2017 in the Division of Pediatric Infectious Diseases in our hospital were examined retrospectively.Results:The median age of the patients was 8,8 (range, 0,4–17) years and 47.1% were female (n=33). Twenty-seven patients (38.6%) were aged 0–4 years, 15 (21.4%) were aged 5–9 years, and 28 patients (40%) were aged 10–18 years. Forty-four patients (62.9%) were diagnosed as having extrapulmonary tuberculosis and 26 (37.1%) had pulmonary + extrapulmonary tuberculosis. The most common form of extrapulmonary tuberculosis was extrathoracic lymphadenopathy, which was found in 22 patients (31.4%). The other patients were diagnosed as having musculoskeletal system tuberculosis (n=10, 14.3%), gastrointestinal system tuberculosis (n=9, 12.9%), miliary tuberculosis (n=8, 11.4%), intrathoracic lymphadenopathy (n=7, 10%), renal tuberculosis (n=6, 8.6%), central nervous system tuberculosis (n=5, 7.1%), and pleural tuberculosis (n=3, 4.3%). Among a total of 58 patients in whom tuberculin skin test and interferon gamma release tests were studied together, tuberculin skin test positivity (n=37, 63.8%) was found with a higher rate compared with interferon gamma release test positivity (n=32, 55.2%), but the difference was not statistically significant (p=0.35). The median treatment period was 12 (range, 6–24) months. Among the patients whose treatments were terminated, improvement was observed in 52 patients (74.2%) and the development of sequela was observed in six patients (8.5%). Two patients who were diagnosed as having central nervous system tuberculosis (2.8%) died.Conclusion:Clinical, laboratory, and radiologic data should be evaluated together when making a diagnosis of extrapulmonary tuberculosis in children. Interferon gamma release tests alone are not superior to tuberculin skin test, but should be considered to be used in combination in the diagnosis.

The Role of Molecular Techniques for the Detection of Mycobacterium Tuberculosis Complex in Paraffin-embedded Biopsies.

Extrapulmonary tuberculosis (EPTB) is increasingly frequent in developed countries. When it is not clinically suspected, samples are not collected for culture and the only material available is a tissue paraffin block. The aim of this study was to evaluate FluoroType MTB (FT-MTB) and GenoType MTBDRplus methods for the detection of Mycobaterium tuberculosis complex in paraffin-embedded biopsies comparing the results to tuberculosis diagnosis. A total of 17 paraffin-embedded tissues from different locations revealing granulomas were referred to the Mycobacteriology Laboratory and FT-MTB and GenoType MTBDRplus methods were performed. EPTB diagnosis was reached based on histologically compatible lesions, response to treatment and absence of alternative diagnosis. This case definition was considered gold standard for the assessment of the 2 molecular techniques performance. Of the 17 individuals included in the study, 10 were clinically classified as EPTB and in 7 cases tuberculosis was ruled out. Of the 10 patients classified as EPTB, 6 (60%) obtained both FT-MTB and MTBDRplus positive results. Sensitivity and specificity were 60% and 71.4%, and 60% and 85.7% for FT-MTB and MTBDRplus, respectively. Molecular techniques might be useful tools for detection of Mycobaterium tuberculosis complex in paraffin-embedded biopsies especially when there is no sample available for culture.

Soluble urokinase-type plasminogen activator receptor as a biomarker of treatment response in childhood tuberculosis.

Childhood tuberculosis (TB) is a major health problem worldwide, especially in developing countries. In 2015, there are estimated 950,000 cases of childhood TB. Since most TB in children is paucibacillary, this gives rise not only to problem in diagnosing but also in monitoring the response to anti-TB treatment as well. Soluble urokinase-type plasminogen activator receptor (suPAR), a glycosylphosphatidylinositol-linked membrane protein of various cells of immune system, is one of the potential biomarkers to be used in the management of TB. The objective of this study is to study the decrease of serum suPAR level after anti-TB treatment in children with TB and its association with patient characteristics. We conducted a prospective study on children suspected of having TB due to a history of contact with active TB case and symptoms such as coughing, fever, and enlarged lymph nodes. The diagnosis of TB is established by history, physical examination including anthropometric examination. Tuberculin skin test using PPD RT-23 and interferon-gamma releasing assay with Quantiferon TB-Gold Plus was performed. Chest X-rays were read by two independent radiologists. Microbiological examination was performed using microscopic examination and Xpert MTB/RIF. The level of suPAR before and after anti-TB treatment was examined with the Elisa method. There was no significant difference of serum suPAR levels before and after anti-TB treatment (mean 0.71 [standard deviation 0.585] ng/mL; P = 0.072). There was no association between ages (P = 0.112), nutritional status (P = 0.228), diagnosis of pulmonary or extrapulmonary TB (P = 0.956), and radiological feature (P = 0.810) with serum suPAR levels decrease. There is no suPAR serum level decrease 2 months after treatment with anti-TB and there is no association with age, nutritional status, pulmonary or extrapulmonary TB diagnosis, and radiological feature.

Diagnostic Value of Serum Adenosine Deaminase Level in Extrapulmonary Tuberculosis

Background: Although tuberculosis is a known disease, still on occasion, the tuberculosis patients remain undiagnosed and hence not treated appropriately. In some cases, the patient is not able to give a proper sputum sample. In some other cases, expert laboratory technician to examine the patient’s sputum smear is not available. Furthermore, and in most cases of extrapulmonary tuberculosis, invasive diagnostic procedures such as biopsy might be followed. The aim of this study was to investigate the diagnostic value of serum level of adenosine deaminase (ADA) in extra pulmonary tuberculosis. Methods: In this analytical study, pulmonary tuberculosis patients were compared with two other groups of patients including lung cancer patients and healthy controls, based on national tuberculosis protocol. In each group, 40 patients who almost matched for age and sex were included. Blood samples were taken from the participants to measure serum ADA levels. Data were analyzed using SPSS software version 15.0. Results: Based on the data analyzed in this study, the mean ADA level in the patients with extra pulmonary tuberculosis was 23.8 IU/L which was significantly higher than that in the other groups (P<0.001). Mean ADA levels in lung cancer patients and in healthy subjects were 15.8 IU/L and 10.7 IU/L, respectively. Conclusions: According to the results of this study, higher cut-off value for ADA would increase the specificity up to 100%. Moreover, serum ADA level can be a valuable additional index in diagnosis of extra pulmonary tuberculosis.

Xpert MTB/RIF assay for the diagnosis of extrapulmonary tuberculosis: a diagnostic evaluation study

ObjectivesThe diagnosis of extrapulmonary tuberculosis (EPTB) is often made on clinical suspicion alone, resulting in both under- and overdiagnosis and relatively poor outcomes. In this study, we evaluated the clinical utility of the Xpert MTB/RIF on routinely collected extrapulmonary specimens in Ethiopia. MethodsThis study was carried out at Jimma University Specialized Hospital, Southwest Ethiopia. Extrapulmonary specimens were collected from 572 patients clinically suspected of suffering from EPTB. All specimens were tested for TB by smear microscopy, culture, and Xpert MTB/RIF. The diagnostic accuracy of Xpert MTB/RIF was calculated and compared to a composite reference standard (CRS), comprising clinical and laboratory results. ResultsIn total, 572 extrapulmonary specimens (279 lymph node, 159 pleural, 80 peritoneal, 45 cerebrospinal, and nine pericardial fluids) were tested. The pooled sensitivity and specificity of Xpert MTB/RIF were calculated to be 75% (95% CI 70–80) and 98% (95% CI 97–100) respectively when compared to the CRS. The highest sensitivity was documented for lymph node specimens (90%; 95% CI 86–94), moderate sensitivity for cerebrospinal fluid (53%; 95% CI 28–79), while the sensitivity was lowest for pleural (30%; 95% CI 17–44) and peritoneal (32%; 95% CI 12–51) fluids. Xpert MTB/RIF in addition detected rifampicin resistance in 13 patients, in perfect agreement with results from the line probe assay. ConclusionsXpert MTB/RIF may be used as initial diagnostic tool for testing of lymph node specimens from patients suspected of having TB lymphadenitis. The added value of Xpert MTB/RIF to diagnose pleural or peritoneal TB is limited by its poor sensitivity.

Application of 18F-FDG PET/CT in the diagnosis of extrapulmonary tuberculosis

ObjectiveThis study aimed to evaluate the diagnostic value of positron emission tomography/computed tomography(PET/CT) for detecting the infective lesions in patients with extrapulmonary tuberculosis (EPTB). MethodsThe PET/CT imaging findings of 46 patients with extrapulmonary tuberculosis were analyzed retrospectively. Of the 46 patients, the standard uptake value (SUV) was calculated, and the maximum SUV (SUVmax) was measured. Characteristic imaging findings and SUV of EPTB in PET/CT were summarized. ResultsPET/CT demonstrated different degrees of increased 18F-FDG uptake in EPTB patients, with the SUVmax ranging from 1.3 to 30.0. Based on the involved organ and tissue, there were 4 types of lesions, including lymph node tuberculosis (25 cases), membranous tuberculosis (13 cases), organ tuberculosis (13 cases) and osteoarticular tuberculosis (8 cases). Of the 46 cases, 11 had two or more than two types of lesions. In the 25 cases of lymph node tuberculosis, slight or moderate lymphadenopathy were revealed by CT, and nodular or mass-like increased 18F-FDG uptake were found by PET, with SUVmax ranged from 3.0 to 30.0. In the 13 cases of membranous tuberculosis, the lesions involved meninx, pericardium, pleura and peritoneum. And PET/CT demonstrated different degrees of membranous thickening, with the SUVmax ranging from 1.3 to 14.5. In the 13 cases of organ tuberculosis, the lesion involved liver, spleen, pancreas, colon, prostate, seminal vesicle and ovary, with the SUVmax ranging from 2.5 to 15.6. In the 8 cases of osteoarticular tuberculosis, osteolytic bone destruction was found. The lesions showed increased 18F-FDG uptake on the PET/CT, with SUVmax ranging from 3.5 to 19.2. ConclusionThere were some imaging characteristics of EPTB by PET/CT. PET/CT can accurately demonstrate the pathological morphology, extent of involvement and uptake activity of EPTB, and provided information in accurate diagnosis, differential diagnosis and assessment of treatment response of EPTB.

Evaluation of GeneXpert MTB/RIF assay in diagnosis of extrapulmonary tuberculosis and rifampicin resistance

Background: The prevalence of tuberculosis is still on the rise particularly extrapulmonary cases. There is an urgent need for rapid diagnosis of these cases for prompt initiation of treatment. Aim: To evaluate the role of GeneXpert MTB/RIF Assay in the diagnosis of clinically suspected extrapulmonary tuberculosis (EPTB) and to detect rifampicin resistance in these cases. Materials and methods: A total of 241 samples from April 2016 to July 2018, from all clinically suspected EPTB patients with support of either laboratory or radiological evidence were included in study. 132 pleural fluid, 59 lymph node aspirate, 21 CSF, 17 pus, 9 ascitic fluid and 3 synovial fluid samples were screened for presence of acid fast bacilli (AFB) by conventional Zeihl-Neelsen (ZN) technique. The same samples were also used for testing by GeneXpert MTB/RIF Assay. Results: Out of 241 EPTB samples tested, none were positive for AFB by ZN staining. Overall 9.54 % (23 out of 241) samples were positive for MTB by GeneXpert with a positivity rate of 23.80%, 13.55%, 11.76% & 6.06% respectively for CSF, lymph node aspirate, pus and pleural fluid. MTB was not detected in any of ascitic fluid & synovial fluid samples. Of the 23 MTB positive samples detected by GeneXpert, all were sensitive to rifampicin. Conclusions: GeneXpert was found to be simple, effective and useful diagnostic method for detection of EPTB due to its rapidity & simultaneous detection of rifampicin resistance, thus reducing the time taken for initiation of treatment.

Clinical and laboratory features of PCR-confirmed periocular tuberculosis in China

Experts lack knowledge of periocular tuberculosis (TB) in China. Nested polymerase chain reaction (PCR) shows advantages in diagnosis of extrapulmonary TB. Our study aims to explore the clinical and laboratory features of PCR-confirmed periocular TB. We retrospectively reviewed medical records of presumptive periocular TB and performed nested PCR test to confirm diagnosis. Nine cases were recruited. Clinical symptoms were chronic and insidious. Eight cases achieved favorable visual acuity, while one underwent enucleation due to fungal-TB panophthalmitis. Sensitivity of caseous necrosis, acid-fast bacilli (AFB) staining and interferon γ release assay (T-SPOT) test are 33.3%, 44.4% and 85.7% respectively. Low lymphocyte percentage (P=0.019) and high monocyte-lymphocyte ratio (P=0.042) positively correlate with AFB staining. Male gender (P=0.048) and Langhans giant cell (P=0.048) positively correlate with caseous necrosis. To conclude, traditional TB ancillary tests are not as sensitive as nested PCR technique. Several factors facilitate diagnosis including male gender, decreased lymphocytes, and typical Langhans giant cells.

AN ATYPICAL PRESENTATION OF TB: A CASE REPORT

SESSION TITLE: Chest Infections 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Mycobacterium tuberculosis is the leading infectious cause of death from any single organism in adults. More than two billion people are estimated to be infected with TB worldwide. It usually involves the lungs, but can also present as extrapulmonary TB. (approximately two thirds of people will have pulmonary tuberculosis while less than a third of immuncompetent individuals will have extrapulmonary tuberculosis alone) The diagnosis of extrapulmonary TB can be difficult and often requires a high index of suspicion. We present a case of TB that manifested as a tubercular retropharyngeal abscess. CASE PRESENTATION: A 67 year old female from Vietnam presented complaining of 2 months of worsening posterior neck pain, which progressed to dysphagia to liquids and solids and was associated with weight loss. At presentation she denied any fevers, chills, chest pain, cough, hemoptysis or any other symptoms. On examination she was afebrile, well appearing with normal vital signs, normal pulmonary, cardiac and abdominal examination; but she had left anterior neck tenderness to palpation. Laboratory data was unrevealing. She underwent MRI of the cervical spine to evaluate her neck pain, and the MRI showed C1-C2 retropharyngeal abscess with osteomyelitis of C2 with considerable bone destruction. A Barium swallow study showed a fistulous connection to the retropharygeal space. A CT scan of the chest showed multiple bilateral pulmonary nodules. She underwent incision and drainage of the retropharyngeal abscess with significant improvement in symptoms . Abscess drainage grew Klebsiella pneumoniae. The smear was negative for AFB, but the culture became positive after 21 days for pan-susceptible Mycobacterium Tuberculosis. Gastric drainage and sputum AFB were negative. She was started on high dose steroids and anti-tuberculous treatment after the culture from the retropharyngeal abscess became positive. A PEG tube was placed for nutrition and administration of medications. After 6 weeks of anti-tuberculous treatment and steroid therapy,a fluoroscopy swallow study was repeated which showed resolution of the previously seen fistula and a significant decrease in the size of the retropharyngeal abscess. She completed one year of anti-tuberculous treatment for osteomyelitis related to Mtb. DISCUSSION: Tubercular retropharyngeal abscess is an uncommon cause of neck pain and dysphagia and is an atypical presentation of tuberculosis. It requires a detailed history and physical exam in addition to a high index of suspicion. Early recognition and treatment is essential to prevent serious complications from mediastinitis, airway obstruction, up to paraplegia that could be caused from severe osteomyelitis. CONCLUSIONS: TB is a disease with high prevalence worldwide. TB can have many different clinical presentations and is important to keep it in consideration as differential diagnosis in suspicious cases. Reference #1: Colmenero JD, Jiménez-Mejías ME, Reguera JM, Palomino-Nicás J, Ruiz-Mesa JD, Márquez-Rivas J, et al. Tuberculous vertebral osteomyelitis in the new millennium: Still a diagnostic and therapeutic challenge. Eur J Clin Microbiol Infect Dis. 2004;23:477–83 Reference #2: Marques PM, Spratley JE, Leal LM, Cardoso E, Santos M. Parapharyngeal abscess in children: Five year retrospective study. Braz J Otorhinolaryngol. 2009;75:826–30 Reference #3: Harkani A, Hassani R, Ziad T, Aderdour L, Nouri H, Rochdi Y, et al. Retropharyngeal abscess in adults: Five cases reports and review of the literature. Scientific World Journal. 2011;11:1623–9. DISCLOSURES: no disclosure on file for Ashkin David; No relevant relationships by Megan Ninneman, source=Web Response No relevant relationships by Yoslay Perez, source=Web Response No relevant relationships by Rene Rico, source=Web Response No relevant relationships by Andreas Schmid, source=Web Response

Extrapulmonary tuberculosis in the setting of HIV hyperendemicity at a tertiary hospital in Durban, South Africa

Background: South Africa has the highest burden of tuberculosis/human immunodeficiency virus (TB/HIV) co-infection in the world, with the province of KwaZulu-Natal representing the global epicentre of TB/HIV. While significant progress has been made to improve the diagnosis of pulmonary tuberculosis, the diagnosis of extrapulmonary TB (EPTB) remains a significant challenge in resource-constrained settings. Methods: A retrospective chart review was conducted, and included all adult patients diagnosed with EPTB at a tertiary hospital in Durban, South Africa, between January 1, 2016 and March 31, 2016.Results: There were 188 new cases of TB during the study period, with 80 patients diagnosed with EPTB. The mean age of patients was 34.73 (SD ± 9.44) years. Forty-two (52.5%) patients were female, while 76 (96%) were black. The most common risk factor for EPTB was HIV co-infection (88.8%). The median CD4 cell count was 68 (IQR 32–165) cells/mm3. Pleural (36.3%), lymph node (28.7%) and abdominal (27.5%) involvement were the most common sites of disease Weight loss, fever, night sweats and cough were amongst the most common symptoms reported. A microbiologically confirmed diagnosis was made in only 65% of cases. In the majority of cases, more than one diagnostic method was used to confirm the presence of TB in distant organs.Conclusion: Immunosuppression, most commonly by HIV, remains the most significant risk factor for the development of EPTB. Advancements in Xpert MTB/Rif and computed tomography have assisted in increasing the diagnostic armamentarium of EPTB. Despite improved access to antiretroviral therapy over the past years, advanced HIV disease remains a significant challenge to TB control.