Positive Acid-fast Bacilli Staining Research Articles

Liver Mass Caused by Mycobacterium fortuitum: A Rare Case Diagnosed by EUS-FNA

ABSTRACT Mycobacterium fortuitum is associated with skin and soft-tissue infections, yet isolated liver involvement is rare. A 67-year-old asymptomatic man was referred for endoscopic ultrasound (EUS) to evaluate a gastric lesion and an incidental liver mass. EUS revealed a heterogeneous liver mass that was sampled. Pathology revealed necrotic granulomatous inflammation and positive acid-fast bacilli stain with M. fortuitum deoxyribonucleic acid. Levofloxacin plus trimethoprim and sulfamethoxazole for 3 months were used for complete resolution of liver lesion. Isolated nontuberculous liver involvement is uncommon. We report the first case of a liver mass caused by M. fortuitum diagnosed by EUS-fine needle aspiration.

Clinical Characteristics of Pulmonary Tuberculosis in Children Tested by Xpert MTB/RIF Ultra.

The Xpert MTB/rifampicin Ultra (Xpert Ultra) assay improves the early diagnosis of active tuberculosis (TB) in children. Clinical evaluation is paramount for the interpretation of any positive Xpert Ultra test, especially those with low quantities of DNA. In this study, 391 children with suspected TB who were tested with Xpert Ultra were enrolled. The clinical characteristics and Xpert Ultra results were further analyzed. The sensitivity and specificity of Xpert Ultra were 45.0% (149/331) and 96.7% (58/60), respectively. Children with higher semiquantitative scales of Xpert Ultra showed higher percentages of a positive MTB culture, positive acid-fast bacilli staining, severe type of disease, fever, cough and expectoration, a higher white blood cell count and higher C-reactive protein concentrations (all P < 0.01). Among 44 children with an Xpert Ultra trace result, there were no differences in clinical characteristics between confirmed cases and unconfirmed TB cases. The prevalence of trace is relatively high and can be considered positive in paucibacillary children. Clinical presentations are associated with bacterial load quantified by Xpert Ultra. The interpretation of Xpert Ultra trace results based on clinical information is important for the diagnosis of TB.

Role of Fine Needle Aspiration Cytology in Extrapulmonary Tuberculosis

Introduction: Extrapulmonary tuberculosis is equally important as that of pulmonary tuberculosis. Fine needle aspiration cytology (FNAC) is accurate, cost effective, minimal invasive outpatient procedure and aids in prompt diagnosis of extrapulmonary tuberculosis.&#x0D; Aims: To determine the role of fine needle aspiration cytology for diagnosis of extra pulmonary tuberculosis.&#x0D; Methods: This is a hospital based descriptive study done over a period of one and half year April 2019 to October 2020 at Nepalgunj Medical College Teaching Hospital, Nepalgunj, Nepal. All the 80 patients who were clinically suspected for tuberculosis had undergone fine needle aspiration cytology and diagnosed as tuberculosis in cytology were included in study. Cytological diagnosis was made with microscopic features and positive acid fast bacilli staining. Microscopy showed epithelioid histiocytes, granulomas, multinucleated giant cells, caseous necrosis, neutrophils and mature lymphocytes.&#x0D; Results: Out of 930 cases received, 80 cases were diagnosed as tuberculosis in cytology. 33 cases were diagnosed with acid fast bacilli positive. Rest was diagnosed with cytological features. Among 80 aspirated samples, a portion of purulent specimen was evaluated with Genexpert test in 11 cases for Mycobacterium Tuberculosis detection and rifampicin sensitivity/ resistant. Out of 11 positive patients in Genexpert tests; 10 were rifampicin sensitive and one was rifampicin resistant.&#x0D; Conclusion: Common presentation of extrapulmonary tuberculosis is in lymph nodes with increased frequency in age group of 21 to 30 years. Therefore, lymph nodes in this age group should be prioritized more for investigation of extrapulmonary tuberculosis.

Clinical and Cytomorphological Patterns of Granulomatous Inflammation and its Correlation with Ziehl–Neelsen Staining

Introduction: Tuberculosis (TB) is one of the leading causes of mortality and morbidity in India, and extrapulmonary cases from the lymph nodes account for one-fifth of the overall disease burden. TB is known for its varied clinical presentations as well as different sites (organs) of involvement. Fine-needle aspiration cytology (FNAC) plays an important role in diagnosing a significant number of cases which present as granulomatous lesions. Here, we study the cytomorphological and clinical presentation of swellings showing granulomatous pattern of inflammation and correlate them with acid-fast bacilli (AFB) positivity. Materials and Methods: A retrospective study of 3-years duration was done from January 2018 to December 2020 in a tertiary care hospital. Slides of 356 cases showing epithelioid granulomas on cytology were taken out. The clinical data were collected from patient requisition forms. All the available clinical and cytological findings were recorded. The slides were re-examined and characterized into specific patterns of granulomatous inflammation on the basis of predominant background population of cells, necrosis, and hemorrhage. These were correlated with the presence of positive AFB staining on Ziehl–Neelsen (ZN) stain. Chi-square test was used for comparison between groups and P &lt; 0.05 was taken to be statistically significant. Results: The mean age of presentation was 25 years (ranging from 5 months to 75 years) with a slight female preponderance (male-to-female ratio being 0.9:1). The cervical lymph nodes were the most common site. The sites of presentation were varied. The aspirates were gray–white to blood mixed on gross and cytological examination in 186 cases (52.25%). On microscopy, the suppurative pattern was seen in 202 cases (56.74%) and necrosis was seen in 182 cases (51.12%). The AFB positivity on ZN staining was seen in 96 (26.96%) cases in FNAC smears. There was a significant association of positive AFB staining with younger age group (&lt;25 years), larger sized swellings (&gt;2 cm), fixed and matted swellings, longer duration of symptoms (&gt;2 weeks), and absence of pain and fever. The whitish/purulent aspirates on gross examination as well as suppurative and necrotic patterns on cytomorphology on microscopic examination showed a highly significant positive correlation with AFB staining. Conclusion: The gross and microscopic patterns of suppuration and necrosis on FNAC in combination with clinical signs and symptoms are highly suggestive of TB. ZN staining on cytology smears is a very simple and useful investigation, especially in suppurative and necrotic patterns of cytology, for clinching an early diagnosis, which goes a long way in the management of tuberculosis.

The impact of adjuvant surgical treatment of nontuberculous mycobacterial pulmonary disease on prognosis and outcome

BackgroundLung resection in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) has been reported to be associated with favorable outcomes. However, little is known regarding the risk and prognostic factors for refractory and recurrent cases. We aimed to evaluate the overall impact and benefit of adjuvant lung surgery by comparing NTM-PD patients who underwent adjuvant lung resection with those treated exclusively with antibiotics. We also investigated the efficacy of serum IgA antibody against glycopeptidolipid (GPL) core antigen (GPL core antibody) to monitor disease activity and predict the recurrence of disease after adjuvant lung resection.MethodsWe retrospectively evaluated the clinical characteristics and surgical outcomes of 35 patients surgically treated for NTM-PD. Furthermore, we compared surgically treated patients and control patients treated exclusively with antibiotics who were matched statistically 1:1 using a propensity score calculated from age, sex, body mass index, and radiologic features of disease.ResultsIn the surgically treated patients, the median age was 58 (interquartile range, 47–65) years and 65.7% were female. Twenty-eight patients had Mycobacterium avium complex. Operations comprised four pneumonectomies, two bilobectomies, one bilobectomy plus segmentectomy, 17 lobectomies, two segmentectomies, and nine lobectomies plus segmentectomies. Postoperative complications occurred in seven patients (20%), there were no operative deaths, and 33 (94.3%) patients achieved negative sputum culture conversion. Refractory and recurrent cases were associated with remnant bronchiectasis, contralateral shadows, and positive acid-fast bacilli staining or culture. Of 28 statistically matched pairs, long-term sustained negative culture conversion was observed in 23 (82.2%) surgical group patients and in 14 (50.0%) non-surgical group patients (0.0438). The mortality rate was lower in the surgical group, but did not reach statistical significance (one in the surgical group and four in the non-surgical group, p = 0.3516). GPL core antibody was correlated with disease activity and recurrence.ConclusionsNTM-PD patients who underwent adjuvant lung resection experienced overall favorable outcomes and achieved sputum culture conversion more frequently. Long-term mortality may have been reduced by this procedure, and the level of GPL core antibody was shown to be a good clinical indicator of disease activity after surgery.

926. Outbreak of Invasive Nontuberculous Mycobacterium (NTM) Infections Associated With a Pediatric Dental Practice

BackgroundIn 2016, an Orange County, California, pediatric dental clinic’s contaminated water system led to the largest outbreak of odontogenic NTM infections yet described.MethodsMandatory reporting and active case finding directed by County Public Health were conducted in collaboration with community Pediatric Infectious Disease physicians for patients who underwent pulpotomy at Dental Clinic A from January 1 to September 6, 2016. Confirmed cases were those with positive NTM culture. Probable cases were those with multiple pulmonary nodules on computed tomography (CT), necrotic bone or osteomyelitis seen at surgery, or pathology with positive acid-fast bacilli stain, granulomatous inflammation or chronic osteomyelitis. Clinical data was collected from medical records.ResultsOf 1,089 patients at risk, 71 cases (22 (31%) confirmed and 49 (69%) probable) (Figure 1) had been identified as of March 19, 2018 (Figure 2). Median case age was 6 years (range 2–11 years). Symptoms began a median of 85 days (range 1–409 days) after pulpotomy (Figure 3). Pain and/or swelling on admission were reported in 79%; 21% were asymptomatic. CT findings included 49/70 with abnormalities of the mandible or maxilla, 13/70 with lymphadenopathy, and 19/68 with pulmonary nodules. Only 6/60 had erythrocyte sedimentation rate >40 mm/hour. Of 71 cases, 70 were hospitalized and underwent surgical debridement, for an average of 8.5 inpatient days (range 1–60 days); 23 had >1 hospitalization and 26 required >1 inpatient surgery. Permanent teeth were lost in 45/65 (range of 1–6 teeth lost). Intravenous antibiotics were administered to 32 cases for a median length of 137 days (range 113–282 days). Clofazimine was obtained for 29/32 cases as part of the regimen. Medical therapy was complicated by peripherally inserted central catheter malfunction/replacement/infection (18/27), rash (2/27), neutropenia (12/27), and elevated creatinine (7/27). All treated children showed evidence of jaw healing with resolved or improving lung nodules at 1-year follow-up.ConclusionThis is the largest outbreak of invasive NTM infections seen associated with a pediatric dental practice. While infections were indolent, patients suffered medical and surgical consequences of treatment. Enhanced national dental water quality standards are needed to prevent future outbreaks. Disclosures A. Arrieta, Melinta Therapeutics: Investigator, Research support

The role of laboratory investigations in evaluating abdominal tuberculosis.

Background and Objectives:Tuberculosis (TB) continues to be a major health problem in developing countries like India. Abdominal TB is defined as an infection of the peritoneum, or hollow or solid abdominal organs with Mycobacterium tuberculosis (Mtb). The gastrointestinal tract is one of the most frequent sites of extrapulmonary involvement in TB. The present study was undertaken to evaluate the role of laboratory investigations in the diagnosis of abdominal TB.Materials and Methods:The study was conducted on 300 patients admitted to various departments of our hospital from November 2005 to October 2007. Detailed histories and thorough clinical examinations together with relevant hematological, biochemical, cytological, radiological, and histopathological investigations were carried out in suspected cases of Koch's abdomen.Results:Erythrocyte sedimentation rates with positive results were seen in 79.3% patients. Serological test enzyme-linked immunosorbent assay was performed on only 30 patients and was found to be positive for IgG, and IgM in 25 cases with a sensitivity of 83%. Thirteen out of 15 cases were positive for adenosine deaminase done on ascitic fluid. The results of the two patients who underwent Mtb polymerase chain reaction (PCR) were consistent with TB. Out of 21 image-guided fine-needle aspiration cytology (FNAC) cases, 10 (48%) of the positive cases showed caseating necrosis while 7 (33%) had noncaseous necrosis. Stain for acid-fast bacilli (AFB) was performed on all cases and was positive in 42 cases (38.8%). Lymph node biopsy was done in 95% of the cases.Conclusions:Serological investigations have a limited value, while PCR is a highly specific test. Since cost restricts its use, only two patients in our study could afford it. BACTEC is more sensitive and faster than culture techniques for the diagnosis of mycobacterial infections. FNAC is a reliable, cost effective alternative, and 81% diagnostic yield in the present study suggests that ultrasound guidance is a useful tool. Histopathological evaluation with positive AFB staining remains the gold standard for diagnosing abdominal TB. However, although the demonstration of AFB in aspirates and tissue sections is a definitive diagnostic method for TB, the positivity for AFB is variable.

Culture conversion rate at 2 months of treatment according to diagnostic methods among patients with culture-positive pulmonary tuberculosis.

IntroductionThe culture-negative conversion rate of sputum after 2 months of treatment in patients with pulmonary tuberculosis (TB) is used as a reliable surrogate marker for relapse after completion of treatment. We hypothesized that culture conversion of sputum at 2 months of anti-TB treatment and the time to culture conversion are different among pulmonary TB patients who are diagnosed using different methods.MethodsCulture-confirmed pulmonary TB patients who were diagnosed between 1 January, 2011 and 31 December, 2012 were classified into three groups based on the diagnostic method that prompted treatment initiation: positive acid-fast bacilli (AFB) staining of sputum (smear-positive group), negative AFB staining, but Mycobacterium tuberculosis was cultured from sputum (culture-positive group), and positive AFB staining, positive polymerase chain reaction (PCR) for M. tuberculosis, or culture of M. tuberculosis from a bronchoscopic specimen (bronchoscopy group). Rates of negative mycobacterial culture conversion at 2 months of anti-TB treatment and the time to negative culture conversion of sputum were compared among the three groups.ResultsA total of 203 patients with culture-confirmed pulmonary TB were included in the final analysis. TB patients in the culture-positive group (94.1%) and the bronchoscopy group (97.6%) showed a higher culture conversion rate at 2 months of treatment than those in the smear-positive group (78.7%, P = 0.001). Additionally, the time to culture conversion was longer in the smear-positive group (median, 40 days) than in the culture-positive (median, 19 days; P = 0.009) and bronchoscopy groups (median, 29 days; P = 0.004).ConclusionsThe higher culture conversion rate at 2 months and the shorter time to culture conversion among pulmonary TB patients with a negative AFB smear suggests the feasibility of shortening treatment duration and isolation in these patients.

Intrathoracic and Intraabdominal Tuberculosis Lymphadenitis without Lung Involvement in an Immunocompetent Patient

Extrapulmonary tuberculosis (EPTB) is defined as tuberculosis (TB) affecting organs other than lung. The most common site of EPTB is the lymph node. In adults, lymphadenopathy without a lung parenchymal infiltrate is rare and is usually observed in immunocompromised patients. We report a case of a 53 years old non-immunocompromised women from affected by intrathoracic and intraabdominal tuberculosis lymphadenitis without lung involvement. The patient presented with subacute fever, night sweat, fatigue, anorexia, abdominal pain, and weight loss. The diagnosis was made by the combination of computed tomography (CT) scans and histopathology studies. CT scans showed multiple lymph nodes involvement in the mediastinal and abdominal areas. Histopathology studies showed necrotizing lymphadenitis with positive acid-fast bacilli stain. The patient responded to (rifampin, isoniazid, pyrazinamide, ethambutol) therapy well and was discharged five days after initiating the treatment.

Post traumatic tubercular osteomyelitis of skull vault

Post traumatic tubercular osteomyelitis of skull vault

Causes and Predictive Factors Associated with "Diagnosis Changed" Outcomes in Patients Notified as Tuberculosis Cases in a Private Tertiary Hospital

BackgroundThe aim of our study was to evaluate the "diagnosis changed" rate in patients notified as tuberculosis (TB) on the Korean TB surveillance system (KTBS).MethodsA total of 1,273 patients notified as TB cases on the KTBS in one private tertiary hospital in 2011 were enrolled in the present study. Patients were classified into three groups: "diagnosis maintained", "diagnosis changed" (initially notified as TB, but ultimately diagnosed as non-TB), and "administrative error" (notified as TB due to administrative errors).ResultsExcluding 17 patients in the "administrative error" group, the "diagnosis maintained" and "diagnosis changed" groups included 1,097 (87.3%) and 159 patients (12.7%), respectively. Common causes of "diagnosis changed" were nontuberculous mycobacterial (NTM) disease (51.7%, 61/118), and pneumonia (17.8%) in cases notified as pulmonary TB, and meningitis (19.5%, 8/41) and Crohn's disease (12.2%) in cases notified as extrapulmonary TB. Being older than 35 years of age (odds ratio [OR], 2.18) and a positive acid-fast bacilli stain (OR, 1.58) were positive predictors and a TB-related radiological finding (OR, 0.42) was a negative predictor for a "diagnosis changed" result via multivariate logistic regression analysis in pulmonary TB cases.ConclusionBecause of a high "diagnosis changed" rate in TB notifications to the KTBS, the TB incidence rate measured by the KTBS may be overestimated. Considering the worldwide trend toward increased NTM disease, the "diagnosis changed" rate may increase over time. Thus, when reporting the annual TB notification rate in Korea, the exclusion of "diagnosis changed" cases is desirable.

Grading of a positive sputum smear and the risk of Mycobacterium tuberculosis transmission

After the diagnosis of a case of tuberculosis (TB), contact tracing is directed by the risk of transmission, for which sputum acid-fast bacilli (AFB) staining results are highly relevant. Limited data are available on the effect of the degree of acid-fast positivity, of a polymerase chain reaction (PCR) result or of bronchoalveolar lavage (BAL) fluid results on the risk of transmission. To investigate factors associated with TB transmission, focusing on quantitative sputum smear results. Retrospective study of contact investigations performed over a period of 5 years in a Dutch Municipal Health Service among all index patients with TB, and the tuberculin skin test and chest radiography results in contacts. Three definitions of transmission were used: ≥ 1 or ≥ 5 contacts with positive TST or active TB in contacts. The highest (+4/+5) sputum AFB grades were associated with the highest relative risk (≥ 8) of extensive transmission or active TB among contacts. Novel risk factors observed were employment or school attendance, positive PCR of sputum and positive AFB staining of BAL fluid. Pulmonary symptoms, infiltrate or cavity and positive AFB sputum stain were also associated with transmission, confirming previous studies. The risk factors observed in this study may aid in the extension of contact investigations.

Comparison of culture and acid-fast bacilli stain to PCR for detection ofMycobacterium tuberculosisin clinical samples

The major drawback in effective use of polymerase chain reaction (PCR) for detectinngMycobacterium tuberculosis(MTB) in clinical samples is the presence of PCR inhibitors and unique cell components of the organism that complicate DNA extraction and subsequent PCR amplification. A PCR assay with a unique multistep DNA extraction method that minimizes these problems was compared in a prospective study to acid-fast bacilli stain (AFBS) and culture for detecting MTB in clinical samples. A total of 254 clinical specimens in two separate studies were processed for MTB by these techniques. While PCR and culture were 100% sensitive and specific, culture required up to 8 weeks of incubation and additional time to perform biochemical testing to identify the isolated micro-oganism. Acid-fast bacilli stain had a specificity of about 87% and did not differentiate amongMycobacterialspecies. In contrast, the results from PCR were available within 48 h and did not require additional testing to attain a final result. Polymerase chain reaction was highly reliable for detection and confirmation and interpretation of positive AFBS results. The assay was easy to perform with a turn around time of about 2 days.

Small lymph nodes of the abdomen, pelvis, and retroperitoneum: usefulness of sonographically guided biopsy.

To evaluate the usefulness of sonographically guided percutaneous biopsy of small lymph nodes in the abdomen, retroperitoneum, and pelvis. From May 1995 through January 1997, 35 sonographically guided lymph node biopsies were performed in 34 patients. All biopsies were performed with a 20- (n = 18) or 22-gauge (n = 10) self-aspirating needle alone or in combination (n = 7). To determine the amount of compression achieved with the transducer, the skin-to-lesion distance on reference computed tomographic (CT) scans was compared with that on sonograms. A biopsy was considered successful if a specific benign or malignant diagnosis was rendered by the pathologist. Of 35 sonographically guided biopsies, 30 (86%) were successful. Diagnoses included 26 (74%) cases of carcinoma, three (9%) cases of benign reactive lymphocytosis confirmed at open biopsy, and one (3%) case of a lymph node with a positive acid-fast bacilli stain. The average lymph node diameter was 2.1 cm (range, 0.9-4.3 cm). With sonography, a mean of 2.5 needle passes (range, 1-5) were made per biopsy. Transducer compression reduced the skin-to-lesion distance from an average of 8.8 cm (at CT) to 4.5 cm. Sonographic guidance seems to provide a reasonable alternative to CT in biopsy of small abdominal, pelvic and retroperitoneal lymph nodes.

Detection of Mycobacterium tuberculosis in formaldehyde solution-fixed, paraffin-embedded tissue by polymerase chain reaction in Pott's disease.

Twenty-five formaldehyde solution-fixed, paraffin-embedded tissue blocks from vertebral biopsy specimen materials with presumptive diagnosis of tuberculous spondylitis and nonspecific vertebral osteomyelitis were studied. To evaluate the sensitivity and specificity of polymerase chain reaction in detecting Mycobacterium tuberculosis in formaldehyde solution-fixed, paraffin-embedded tissue samples from histologically proved tuberculous spondylitis. Diagnosis of a mycobacterial infection is a long and tedious process; because of the slow growth rate of mycobacteria on solid media, identification and antibiotic sensitivity testing can take up to 10 weeks, but the sensitivity of culture can be as low as 50%. Direct microscopy is insensitive because clinical samples may contain only few organisms. Recently, polymerase chain reaction has been applied in the rapid amplification and identification of many organisms, including mycobacteria. The DNAs were extracted from 25 paraffin-embedded tissue blocks. An insertion element IS 6110 (Integrated DNA Tec. Inc., Corrallville, IA), a DNA sequence unique to Mycobacterium complex (M. tuberculosis and the subspecies Mycobacterium bovis), was amplified by polymerase chain reaction. Polymerase chain reaction results were compared with those of Mycobacterium culture, acid-fast bacilli staining, and histologic findings. Polymerase chain reaction was positive in 18 cases of 19 tuberculous spondylitis. Three of the polymerase chain reaction test results were positive with concomitant negative culture and positive acid-fast bacilli staining. There were six chronic nonspecific infections, and polymerase chain reaction results were negative in five cases; in the single positive case, DNA amplification results remained positive even after three repeated tests. Polymerase chain reaction has a sensitivity of 94.7%, specificity of 83.3%, positive predictive value of 94.7%, and a negative predictive value of 83.3%. Accuracy was calculated as 92%.