Index Case Research Articles

Idiopathic multicentric Castleman disease with marrow fibrosis and extramedullary hematopoiesis.

Idiopathic multicentric Castleman disease (iMCD) is a rare inflammatory disorder mediated by excessive proinflammatory cytokine signaling, most notably by interleukin 6 (IL-6). IL-6-induced extramedullary hematopoiesis (EMH) has been reported in murine models of iMCD. Herein we present four cases of iMCD with EMH in humans. The index case is a 24-year-old white woman who presented with pancytopenia, hepatosplenomegaly, and diffuse lymphadenopathy (LAD) with EMH in core lymph node biopsies. We then searched ACCELERATE, a Castleman disease (CD) natural history registry, and identified three additional CD cases with EMH reported in biopsies: A 23-year-old Asian man with fatigue, edema, LAD, and splenomegaly; a 20-year-old white man with fever, dyspnea, LAD, and hepatosplenomegaly; and a 50-year-old white man with constitutional symptoms, LAD, and myelodysplastic syndrome in bone marrow with a KRAS mutation. All four patients presented with thrombocytopenia and fever and/or markedly elevated C-reactive protein. Patient 1 had iMCD-NOS (not otherwise specified) with severe thrombocytopenia, reticulin fibrosis in bone marrow, small volume LAD and organomegaly but no anasarca. The other three patients had iMCD-TAFRO (thrombocytopenia, anasarca, reticulin fibrosis, renal dysfunction, organomegaly). Two had mixed CD and two had hypervascular CD in lymph nodes. All four had bone marrow hypercellularity and megakaryocyte hyperplasia and two had reticulin fibrosis. This case series demonstrates that EMH can be seen in CD, particularly in iMCD-TAFRO. Given the similarity of this finding to previous murine models of IL-6-induced marrow and lymph node changes we hypothesize that this is an IL-6-mediated phenomenon.

Transcatheter stenting of superior vena cava to treat postoperative SVC syndrome in a child: a case report

BackgroundSuperior vena cava (SVC) obstruction leading to SVC syndrome is an uncommon but potential complication of cardiac surgeries that involve dissection and anastomosis around the great vein. We present a case of iatrogenic SVC obstruction that was initially treated with transcatheter balloon angioplasty, which provided temporary relief, and ultimately resolved by stenting the affected segment.Case presentationThe index case underwent total anomalous pulmonary venous connection (TAPVC) repair and presented 3 months after surgery with features of SVC obstruction. Initially, transcatheter balloon angioplasty was performed, providing relief from the obstruction; however, the condition recurred within one month. Finally, the patient was treated with percutaneous stenting of superior vena cava, through femoral venous route, using 8 mm × 30 mm balloon-expandable bare metal stent (Formula 418, Cook Medical, Bloomington, IN). Remarkable relief of obstruction was established with decrease in mean gradient across SVC–right atrium junction to 2 mm Hg (from 12 mm Hg before balloon angioplasty and 18 mm Hg before stenting).ConclusionPercutaneous treatment for iatrogenic SVC obstruction developing after cardiac surgery appears to be effective. Close monitoring is required in the postoperative period for early diagnosis and timely intervention.

Next-generation sequencing in Charcot-Marie-Tooth: a proposal for improvement of ACMG guidelines for variant evaluation

BackgroundThe application of massive parallel sequencing technologies in the molecular analysis of Charcot-Marie-Tooth (CMT) has enabled the rapid and cost-effective identification of numerous potentially significant variants for diagnostic purposes. The...

Intrafamilial Occurrence of Hepatitis B Virus Infection in Family Contacts of HBsAg Positive Subject

Background: Hepatitis B virus (HBV) infection is the global public health challenge. Family members of the HBV infected patients have a high risk of exposure to many blood-borne diseases including Hepatitis B and Hepatitis C viral infections. Of these Hepatitis B is not only the most transmissible infection, but also the only one (HBV) that is preventable by vaccination. Objectives: To assess Occurrence of Hepatitis B Virus Infection in family contacts of HBsAg positive subject. Methods: A six-month cross sectional study was carried out at the department of Medicine, Comilla Medical College. Ethical approval from the institutional review board was obtained to ensure patient privacy and confidentiality. Results: Among 120 selected patients analysis of relatives with the infected patients revealed that most were son and daughters. In the study, out of 379 family members 316(83%) attended the study and 63 (17%) family members were unattended. Among attended family members 37 (11.7%) were known to be positive for HBV, 279 (88.3%) were found negative. Among the study subjects 68 (56.3%) were female and rest 52 (43.8%) were male. Female to male ratio was 1.28:1. Occupation of the study subjects where most were housewives (22.2%) and students (55%). Total 120 index cases, 15 (12.5%) cases were found positive family history for HBV, 90 (75%) were found negative and 15 (12.5%) were unaware of their all family members HBsAg status. Conclusion: Family members staying same house of the HBV infected patients are at highest risk. Total 15(12.5%) index cases were found positive family for HBV infection. So they should take proper preventive measures. J Com Med Col Teachers Asso Jan 2024; 28(1): 14-18

Rate of nosocomial MRSA transmission evaluated via contact screening

BackgroundThe prevention of methicillin-resistant S. aureus (MRSA) transmission in the healthcare setting is a priority in Infection Control practices. A cornerstone of this policy is contact tracing of nosocomial contacts after an unexpected MRSA finding. The objective of this retrospective study was to quantify the rates of MRSA transmission in different clinical settings.MethodsThis multi-centre study included MRSA contact screening results from two regional hospitals and one academic hospital. MRSA contact tracing investigations from 2000 until 2019 were reviewed and post-contact screening results were included of index patients with an MRSA-positive culture and their unprotected contacts. Available typing results were used to rule out incidental findings.ResultsOf 27,377 contacts screened after MRSA exposure, 21,488 were Health Care Workers (HCW) and 4816 patients. Post-contact screening was initiated for a total of 774 index cases, the average number of screened contacts per index case was 35.7 (range 1 to 640). MRSA transmission was observed in 0.15% (41) of the contacts, 19 (0.09%) HCW and 22 (0.46%) patients. The number needed to screen to detect one MRSA transmission was 667. The highest risk of MRSA transmission occurred during patient-to-patient contacts, with transmission rates varying from 0.32 to 1.32% among the participating hospitals. No transmissions were detected in HCW (n=2834) in the outpatient setting, and the rate of transmissions among HCW contacts on the wards was 0.13% (19 of 15,874). Among 344 contacts of patients with contact precautions, no transmissions were detected.ConclusionsReconsidering current MRSA contact tracing practices may lead to a more targeted approach with a lower number needed to screen.

Diagnosis of tuberculosis infection in children with a novel skin test and the traditional tuberculin skin test: An observational study.

A novel skin test-called Diaskintest (DT)-containing specific M. tuberculosis antigens is in clinical use in the Russian Federation (RF). This test may improve diagnosis of tuberculosis (TB) infection. The use and performance of the DT was described and compared to the tuberculin skin test (TST). Data on children <18 years referred to a TB reference centre (Jan/2018- Dec/2019) with ≥1 DT and TST result available were analysed. An immune correlate of TB infection was defined as a positive TST (≥10 mm induration) or a positive DT (any induration). Of 2710 included cases, the median age was 9.0 (IQR 5.7-13.1) years and 97.5% were BCG immunised. Overall, 1976 (79.9%) were TB uninfected, 724 (26.7%) had an immune correlate of TB infection and 10 (0.4%) TB disease. Reasons for referral were: positive or increasing skin test results in routine screening (992, 36.6%), screening before admission to a health care institution (501, 18.5%) and TB contact (457, 16.9%). DT was positive in 11.7% (308/2625) and TST in 63.1% (467/740) (Kappa 0.08, 95% CI:0.013-0.14). A positive DT was associated with older age (OR 1.16 (95% CI: 1.13-1.19) per year). Among TB contacts DT positivity was associated with contagiousness: highest proportion of positivity of 12.0% was observed when the index case was smear positive. In a setting with universal BCG vaccination and regular screening with TST, DT was used to rule out TB infection as TST was commonly positive. We found an association of DT positivity and contagiousness of the index case in children contacts. These observations may suggest improved specificity and sensitivity of DT compared to TST.

Epidemiologic Assessment of Scabies: Actuality of Airborne Transmission and Additional Standards to Reduce Spread of Contagion and Reinfestation

Scabies are caused by parasites that live their entire life within the outer layers of the epidermis. When dislodged either by gravity, friction, motion, wind, or static electricity, they assume great risks to survival. Innate abilities to sense human smell and heat, to move over short distances, and to penetrate the skin quickly allow them a fighting chance to find a new host if they land within 4 inches of a human. Females store sperm, allowing one mite to begin a colony. Transmission is by person-to-person, fomite, and airborne. They are aerodynamic, light, and balloon-shaped, all making airborne transmission easier than previously understood, as well as explaining the dissemination of mites beyond the normal zones of activity of the index case. Presently, the bulk of the medical literature suggests that transmission from inanimate objects poses little concern in common scabies. However, as mites can navigate through cloth gowns, one might consider protection with more protective garb. Mites cannot penetrate through waterproof clothing, and thus, this attire should be recommended to avoid reinfestation and infesting others. Sofas, chairs, office furniture, and car seats on which an index case might sit need to be covered with plastic sheeting. Given that the half-life of ivermectin is 18 hours and that mites dehydrate within 96 hours, strict transmission controls are only needed for 3 days to avoid reinfestation as well as infesting others. Key Points Scabies is an intensely itchy skin rash caused by a burrowing mite that infects the outer layers of the skin. Scabies is contagious and usually spread by direct, prolonged skin-to-skin contact with an infected person; however, fomite and airborne transmission are also operative. Precautions should be in place to avoid direct skin-to-skin contact between a patient with scabies and visitors. Water-proof clothing would be advisable, especially in cases involving Norwegian scabies. Success rates with oral ivermectin would more closely approach 100% if all transmission factors, including fomite and airborne, were addressed.

Health worker perspectives on barriers and facilitators of tuberculosis investigation coverage among index case contacts in rural Southwestern Uganda: a qualitative study

BackgroundIn 2012, the World Health Organization recommended screening and investigation of contacts of index tuberculosis patients as a strategy to accelerate detection of tuberculosis (TB) cases. Nine years after the adoption of this recommendation, coverage of TB contact investigations in Uganda remains low. The objective of this study was to examine health care providers’ perceptions of factors influencing coverage of TB contact investigations in three selected rural health facilities in Mbarara district, southwestern Uganda.MethodsThis study identified provider opinions on the barriers and facilitators to implementation of TB contact investigation using the Consolidated Framework for Implementation Research. Using an exploratory qualitative study design, semi-structured interviews with 19 health workers involved in the TB program at district, health facility and community levels were conducted from April 2020 and July 2020. Analysis was conducted inductively using reflexive thematic analysis in six iterative steps: familiarizing with the data, creating initial codes, searching for themes, reviewing themes, developing theme definitions, and writing the report.ResultsNineteen health care workers participated in this study which translates to a 100% response rate. These included two district TB and leprosy supervisors, five nurses, five clinical officers, six village health team members and one laboratory technician. The three themes that emerged from the analysis were intervention-related, health system and contextual factors. Health system-related barriers included inadequate or delayed government funding for the TB program, shortage of human resources, insufficient personal protective equipment, and a stock-out of supplies such as Xpert MTB cartridges. Contextual barriers included steep terrain, poverty or low income, and the stigma associated with TB and COVID-19. Facilitators comprised increased knowledge and understanding of the intervention, performance review and on-the-job training of health workers.ConclusionsThis study found that most of the factors affecting TB contact investigations in this rural community were related to health system constraints such as inadequate or delayed funding and human resource shortages. This can be addressed by strengthening the foundational elements of the health system - health financing and human resources - to establish a comprehensive TB control program that will enable the efficient identification of missing TB patients.

Index cases of familial medullary thyroid carcinoma show different clinical presentation and outcome compared to sporadic cases

Index cases of familial medullary thyroid carcinoma show different clinical presentation and outcome compared to sporadic cases

Proactive systematic hemophilia carrier screening: a step toward gender equity in hemophilia care

AbstractDespite numerous efforts to raise awareness, many hemophilia carriers and female persons with hemophilia (PWHs) remain undiagnosed. Between May 2021 and April 2023, we identified potential and obligate carriers of hemophilia A (HA) and hemophilia B (HB) by updating pedigrees of all PWHs followed at the Cliniques universitaires Saint-Luc, Brussels. Retrospective data on previously screened females were collected, including bleeding history, coagulation factor levels, and testing for the proband’s pathogenic variant. In addition, a proactive approach involved sending 125 invitation letters to unscreened or incompletely screened individuals, through related PWHs. In pedigrees of 287 male PWHs (226 HA and 61 HB) and 7 female index patients from 236 families (184 HA and 52 HB), a total of 900 female individuals were identified. Of those, 454 were obligate and/or genetically proven carriers, and 118 were noncarriers. Genetic testing was conducted in 133 obligate, 237 potential, and 4 sporadic carriers, with 190 obligate and 328 potential carriers remaining untested. Among carriers with known factor levels (261/454), 42 HA (23.0%) and 23 HB carriers (29.5%) had a factor level <40 IU/dL. Carriers with a factor deficiency were screened on average 6 years earlier than other females (P = .034). This study, to our knowledge, represents the first systematic effort to identify potential carriers among families of all PWHs within a single center, emphasizing the challenges in comprehensive screening for female individuals genetically linked to one or more PWHs. Such initiatives are vital for achieving equitable access to hemophilia care for all potentially affected individuals, irrespective of gender. This trial was registered at www.ClinicalTrials.gov as #NCT05217992.

L2-hydroxyglutaric aciduria presenting with learning disability and cerebellar signs: A case report

L-2-hydroxyglutaric aciduria (L2HGA) is a rare, autosomal recessive neurometabolic disorder due to variants in the L2HGDH gene, which encodes L-2-hydroxyglutarate dehydrogenase (L2HGDH), an enzyme involved in tricarboxylic acid cycle. Deficiency of L2HGDH causes leukoencephalopathy predominantly affecting the cerebellum. This case presents L2HGA in a 12-year-old Sri Lankan boy born to third-degree consanguineous parents, who also showed learning disability and bilateral cerebellar signs. Magnetic resonance imaging (MRI) of the brain revealed T2/FLAIR hyperintensities in bilateral symmetrical subcortical white matter involving the cerebellum. A diagnosis of 2-hydroxyglutaric aciduria was made after a massive peak of 2-hydroxyglutaric acid (2HG) was observed in the analysis of urine organic acids (UOA) using gas chromatography/mass spectrometry. Genetic variant analysis revealed two heterozygous pathogenic variants in the L2HGDH gene, confirming the genetic diagnosis of autosomal recessive L2HGA. Parental genetic testing confirmed the trans phase of the variants in the index patient and their carrier status of a pathogenic L2HGDH variant. Despite typical clinical features and classical MRI findings, initial clues toward the diagnosis are mainly derived from the UOA analysis. In conclusion, this case underscores the paramount importance of analyzing the UOA profile in the process of identifying rare metabolic causes, such as L2HGA, that contribute to learning disability with neurological involvement in children.

Challenges Facing Two Outbreaks of Carbapenem-Resistant Acinetobacter baumannii: From Cefiderocol Susceptibility Testing to the Emergence of Cefiderocol-Resistant Mutants.

Carbapenem-resistant Acinetobacter baumannii (CRAB) infections are associated with poor outcomes depending on patient's conditions, clinical severity and type of infection, and treatment is challenging given the limited therapeutic options available. The aim of this study was to describe the clinical and microbiological characteristics of two outbreaks caused by CRAB in an intensive care unit (ICU). In addition, the mechanisms of resistance detected in these strains and the treatment chosen according to the available therapeutic options were analyzed. Overall, 28 patients were included. Ten patients (35.71%) had ventilator-associated pneumonia (VAP), ten (35.71%) had a bloodstream infection (BSI), and eight (28.57%) were only colonized. Recurrent infection occurred in 25% (5/20) of infected patients. Two different strains of A. baumannii were isolated from the index patient of the first outbreak. The first strain belonged to the ST85 and carried the blaNDM-1 carbapenemase gene, while the second belonged to the ST2 and carried blaOXA-23, and blaOXA-66 carbapenemase genes. The phylogenetic analysis revealed that the ST2 strain was the cause of the major outbreak, and mutations in the AmpC gene were related to progressive increasing minimum inhibitory concentration (MIC) and finally, cefiderocol-resistance in one strain. The CRAB isolates from the second outbreak were also identified as ST2. Cefiderocol-resistant strains tests identified by the disc diffusion method were involved in 24% (6/25) of nosocomial infections. Using broth microdilution (BMD) ComASP® only, 33.3% (2/6) of these strains were cefiderocol-resistant. All-cause ICU mortality was 21.4%. Conclusions: Cefiderocol is the first approved siderophore cephalosporin for the treatment of CRAB infections. Cefiderocol-resistant strains were related with blaNDM-1 carbapenemase and mutations in the AmpC gene. Cefiderocol-resistant strains or that cannot be properly interpreted by disk diffusion, should be retested using BMD for definitive categorization.

Genotypic spectrum of ABCA4-associated retinal degenerations in 211 unrelated Mexican patients: identification of 22 novel disease-causing variants

The purpose of this study was to analyze and molecularly describe the largest group of patients with ABCA4-associated retinal degeneration in Latin America. Pathogenic variants in ABCA4, a member of the ATP Binding Cassette (ABC) transporters superfamily, is one of the most common causes of inherited visual deficiency in humans. Retinal phenotypes associated with genetic defects in ABCA4 are collectively known as ABCA4-associated retinal degenerations (ABCA4R), a group of recessively inherited disorders associated with a high allelic heterogeneity. While large groups of Caucasian and Asiatic individuals suffering from ABCA4R have been well characterized, molecular information from certain ethnic groups is limited or unavailable, precluding a more realistic knowledge of ABCA4-related mutational profile worldwide. In this study, we describe the molecular findings of a large group of 211 ABCA4R index cases from Mexico. Genotyping was performed using either next generation sequencing (NGS) of a retinal dystrophy genes panel or exome. ABCA4 targeted mutation testing was applied to a subgroup of subjects in whom founder mutations were suspected. A total of 128 different ABCA4 pathogenic variants were identified, including 22 previously unpublished variants. The most common type of genetic variation was single nucleotide substitutions which occurred in 92.7% (408/440 alleles). According to the predicted protein effect, the most frequent variant type was missense, occurring in 83.5% of disease-causing alleles (368/440). Mutations such as p.Ala1773Val are fully demonstrated as a founder effect in native inhabitants of certain regions of Mexico. This study also gives us certain indications of other founder effects that need to be further studied in the near future. This is the largest molecularly characterized ABCA4R Latin American cohort, and our results supports the value of conducting genetic screening in underrepresented populations for a better knowledge of the mutational profile leading to monogenic diseases.

Use of Low-Dose Platelets in Actively Bleeding Patients: A Retrospective Analysis of a Cardiac Surgery Cohort.

During platelet shortages, many hospitals produce low-dose platelets by splitting a standard platelet unit (>3 × 1011 platelets in the United States) in 2, then providing these low-dose units to patients. While low-dose units were previously found to be effective for prophylactic purposes in patients undergoing chemotherapy in the Prophylactic Platelet Dose (PLADO) trial, their use in actively bleeding patients has not yet been assessed. To assess the use and safety of low-dose platelets in actively bleeding patients. We performed a retrospective review of cardiac surgery cases receiving platelet units for 18 months at 1 hospital. Two cohorts, those receiving only whole-dose platelets (37 cases) and those receiving only low-dose platelets (38 cases), were compared during the intraoperative and the 24-hour perioperative period. Mean number of platelet transfusions, dose of other blood products, estimated blood loss, bleeding complications in index cases, and all-cause mortality within 30 days of discharge were compared. There was no significant difference in mean number of intraoperative platelet transfusions between the cohorts (1.61 versus 1.53, P = .57). There was no significant increase in the transfusion of other blood products, estimated blood loss, bleeding complications in index cases, or all-cause mortality within 30 days of discharge in the low-dose platelet cohort, apart from a small increase in requirement for fresh frozen plasma in the perioperative period. These results suggest that low-dose platelets are tentatively equivalent to whole-dose platelets in cardiac surgery during shortages, with similar transfusion requirements and clinical outcomes between groups. Future multicenter studies are needed to confirm these findings.

Tuberculosis treatment loss to follow-up in children exposed at home: A prospective cohort study.

Loss to follow-up (LTFU) from tuberculosis (TB) treatment and care is a significant public health problem. It is important to understand what drives LTFU in children - a population whose treatment and management depend on an adult caregiver - to better provide support services to families affected by TB. We conducted a prospective cohort study of household contacts in Lima, Peru (2009-12). Using multilevel logistic regression analysis, we explored individual-level characteristics of children and their adult household members with TB disease to identify risk factors for LTFU among children initiated on treatment for TB. A total of 154 child (0-14 years) household contacts were diagnosed with TB and initiated on treatment. While most (n = 133, 86.4%) had a successful outcome, 20 (13.0%) children were LTFU. Six (30.0%) children were LTFU within three months, nine (45.0%) between five to seven months, and three (15.0%) after seven months of treatment being initiated. In univariable analysis, children with index patients above 25 years of age had decreased odds of being LTFU (odds ratio = 0.26; 95% confidence interval = 0.08-0.84) compared to children with index patients 25 years or younger. In this cohort, more than 10% of children sick with TB who were exposed to the disease at home were LTFU. An integrated, family-centred TB prevention and management approach may reduce barriers to a child completing their course of TB treatment.

Cardiovascular risk is more important in index cases of familial hypercholesterolemia

Cardiovascular risk is more important in index cases of familial hypercholesterolemia

A questionnaire survey of infection control measures during the coronavirus infectious disease 2019 pandemic era

ObjectiveTo clarify the infection control measures required in the event of a new infectious disease outbreak, we conducted a questionnaire survey on the infection control measures implemented against coronavirus disease 2019 (COVID-19). MethodsAn invitation to participate in this survey was sent to the heads of 2689 facilities affiliated with the members of the Japanese Society for Infection Prevention and Control in February 2023, requesting responses to the online survey using Google Forms by March 2023. ResultsSix hundred and forty-five facilities, including 20 clinics and 625 hospitals, participated in the survey. This survey revealed that various infection control measures were implemented, including universal masking in the non-COVID-19 ward (96.5 %), screening tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on scheduled admission (89.0 %), SARS-CoV-2 tests (98.7 %), and isolation in private rooms (76.5 %) for inpatients with fever. However, nosocomial infections and clusters of COVID-19 occurred in 94.4 % and 90.9 % of cases during the investigation period, respectively. One of the reasons for these results is that healthcare personnel (HCP) and patients were common index cases of nosocomial infections, and the most common cause of clusters was the work of symptomatic HCPs. These results suggest that HCPs should understand that they can be index cases or spreaders. On the other hand, the most common support from external facilities was healthcare centers, followed by physicians or nurses from other hospitals. ConclusionIn response to the emergence of infections, it is important to consider implementing infection control measures for HCPs and patients.

Genetic study of Alport syndrome in Tunisia.

Alport syndrome is a genetic disorder affecting the kidneys, ears, and eyes, causing chronic kidney disease, sensorineural hearing loss, and ocular abnormalities. It results from pathogenic variants in the COL4A3, COL4A4, or COL4A5 genes, with different inheritance patterns: X-linked from COL4A5 variants, autosomal recessive from homozygous variants in COL4A3 or COL4A4, digenic from variants in both COL4A3 and COL4A4, and autosomal dominant from heterozygous variants in COL4A3 or COL4A4. We analyzed 45 patients with Alport syndrome from 11 Tunisian families to determine their clinical and genetic characteristics. Clinical data were collected retrospectively, and whole-exome sequencing was conducted on one patient from each family. Sanger sequencing validated pathogenic variants, and cascade screening extended the analysis to 53 individuals. We identified nine likely pathogenic variants among 11 index cases: six novel and three known variations. Of these, five were in COL4A3, and four were in COL4A5, with variants including frameshift, nonsense, missense, and alternative splicing. Most variations affected the Gly-XY codon. Among the 45 clinically identified siblings, 30 tested positive for Alport syndrome. The cascade screening identified 3 additional affected individuals, 10 unaffected siblings, and 10 unaffected parents. The mode of inheritance was autosomal recessive in six families and X-linked in four families. This study is the first to screen the mutational spectrum of Alport syndrome in Tunisia. It reveals novel pathogenic variants and suggests that autosomal recessive inheritance may be more common in the Tunisian population than X-linked inheritance, contrary to existing literature.

Implementation of Portable Digital Chest X-ray Machine for Tuberculosis Contact Tracing in Oyo and Osun States, Nigeria: A Formative Assessment

This paper presents a formative assessment for the implementation of mobile portable chest X-ray (PDX) machines for tuberculosis (TB) contact tracing in the Oyo and Osun states, Nigeria. This descriptive qualitative study was carried out in eight local government areas, and 24 focus group discussions and 30 key informant interviews were conducted using a four-stage sampling technique to select participants. Validated transcribed notes were entered and analyzed using Nvivo. The respondents’ ages ranged from 17 to 85 years, with a mean age of 42.08 ± 14.9 years, and 4.0% had a postgraduate degree. The majority of government officials stated that deploying the PDX machine for screening at the community level is the best means for implementation because it will offer a level of proximity convenience to the TB contacts and assuage concerns about the cost of transportation to the health facility. In addition, it was suggested that TB community screening should be carried out with screening for other health conditions such as high blood pressure and diabetes. This portable X-ray machine intervention, therefore, should be implemented at the community level for contact tracing to allow more TB contacts living with the index patient to be screened without proximity and transportation constraints.

An Unusual Case of CNS Tuberculoma in a 19-Year-Old Man

Background: Tuberculosis (TB) is ranked as one of the top 10 causes of death. Mycobacterium tuberculosis (M. TB) infection, the causative organism for TB affects approximately a quarter of the global population placing a burden on the healthcare system. Central nervous system tuberculosis (CNS TB) is seen in 5 to 10% of extrapulmonary TB cases and has the highest mortality. CNS tuberculoma is one of its manifestation. Clinical presentation of CNS tuberculoma depends on its location within the CNS and commonly include headache, seizures, and focal neurological deficits, due to the presence of a space occupying lesion, although patients can be asymptomatic. We report the case of a 19yr old man who had an unusual presentation of CNS tuberculoma, highlighting its clinical presentation, diagnosis and treatment. Case Presentation: Index patient is a 19-year-old male college student who resides in a city. He presented with 15 days history of fever, headache, vomiting, vertigo, ataxia, and inability to concentrate. He received antimalarial, anti typhoid and body booster medications but had no improvement and had a history of weight loss despite no dietary change. He had never been diagnosed with TB and had all his childhood vaccinations given. Plain Magnetic Resonance Imaging (MRI) brain scan done revealed a posterior fossa mass lesion with perilesional edema. Futher, a contrast MRI brain scan showed multiple ring-enhancing conglomerates of lesion around the tentorium on the posterior fossa with intense contrast enhancement. The largest of this mass measured 4.5 cm x 2.5 cm x 2.5 cm in the right superior cerebellum compressing the 4th ventricle and with effacement of the cerebellopontine angle. Lastly, an MRI spectrometry revealed elevated lipid lactate peak. His chest x-ray was unremarkable. Other blood parameters were essentially within range with the exception of Erythrocyte ESR and mantoux test. He received antitubercular drug (Isoniazid, Rifampin, Pyrazinamide, Ethambutol, Levoflox and Streptomycin) for 18th months with complete remission. Conclusion: CNS tuberculomas are tuberculous masses that can be located anywhere from the brain to spinal cord. Advanced diagnostic modalities may guide clinicians towards making it's diagnosis. Treatment maybe medical (use of antitubercular drugs) or surgical excision with medical therapy being first choice. While the index patient had no obvious risk factors for his disease, his BCG vaccination pose a possible source of his exposure to TB infection. More research is needed on this however.