Presumptive Pulmonary Tuberculosis Research Articles

Assessment of Conventional and Molecular Methods in the Routine Management of Tuberculosis in a High Tuberculosis Burden Setting

Background and aims: India is a high-burden tuberculosis region and a drug-resistance hotspot. Despite numerous reports of pulmonary tuberculosis (PTB) cases, there needs to be more literature available on the importance of diagnostic methods in the case of extrapulmonary tuberculosis (EPTB). A prospective study was carried out from July 2017 to June 2018 to compare the efficacy of conventional and molecular methods in detecting PTB and EPTB cases. Methods: 1000 presumptive PTB and 412 EPTB cases were subjected to staining (Ziehl-Neelson and fluorescent staining), culture, GeneXpert, and line probe assay. Results: The sensitivity, specificity, and strength of association, i.e., kappa (k) value of LED-FM, ZN, and GeneXpert, were calculated using standard formulae using solid culture as the gold standard. The sensitivity of GeneXpert in smear-positive/culture-positive PTB was comparable with the smear-negative/culture-positive PTB cases (95.7% Vs. 87.5%) with an overall sensitivity and specificity of 90.5% and 90.1% in EPTB cases, respectively. However, sensitivity was lower for pleural fluid (75%) and tissues (85.7%). In pulmonary instances, 10% (6.7% RIF + INH resistant and 3.3%INH monoresistant) drug resistance was observed, and no drug resistance was found in extra-pulmonary samples. Conclusion: Among conventional methods, Fluorescent staining is more sensitive than Ziehl-Neelson (ZN) staining, while the sensitivity of GeneXpert varies w.r.t type of sample using culture positivity as the gold standard. The present study suggests the promotion of universal DST for all individuals with TB to control drug-resistant tuberculosis.

Prevalence of Non-Tuberculosis Mycobacterium Pulmonary Disease in HIV-1 Patients with Presumptive Pulmonary Tuberculosis in Western Kenya.

Non-tuberculous mycobacteria (NTMs) are ubiquitous, free-living, environmental saprophytic microorganisms. NTMs belong to the genus Mycobacterium which includes Mycobacterium tuberculosis (MTB). NTMs have lately been a major cause of pulmonary disease (PD) in immuno-compromised individuals including HIV-1 patients. NTMs and MTB appear similar based on microscopy, radiology, and clinical symptoms; consequently, this may lead to misdiagnosis. This study sought to establish the prevalence of NTM pulmonary disease in HIV-1 patients presumed to have pulmonary tuberculosis. A cross-sectional analytical laboratory study design was used targeting 617 adult HIV-1 infected patients presenting with presumptive pulmonary TB at Bungoma County Hospital Comprehensive Care Clinic in Western Kenya between July 2021 to June 2022. A total of 75 (12.2%, 4.6 -9.8 CI) of the participants presented with presumptive MTB and had TB-like symptoms while 542 (87.8%, 12.5 -30.7 CI) were negative. Additionally, 56 (9.1%) were infected with NTMs. HIV-positive participants had a significantly higher prevalence of NTMs 62 (11.8%, 5.6 -9.2 CI) compared to 2 (2.1%, 0.4 -1.8 CI). In HIV + study participants P<0.0001. M. avium was the most prevalent NTM, 25(33.3%), followed by M. fortuitum 20 (26.7%). A significant number of the isolates were M. tuberculosis 10 (13.3%) as well as M. kansasii 8 (10.7%). There seems to be a high prevalence of NTMPD in HIV-1 patients which is assumed to be pulmonary TB. Differential diagnosis of the mycobacterium species is necessary to help improve disease management and outcomes in this group of patients.

The seroprevalence of anti-Histoplasma capsulatum IgG antibody among pulmonary tuberculosis patients in seven referral tuberculosis hospitals in Indonesia.

Histoplasma capsulatum exposure is rarely suspected in Indonesia. Pulmonary histoplasmosis can occur simultaneously with pulmonary tuberculosis (TB) or as an alternative diagnosis in clinically-diagnosed TB patients with no microbiological evidence of TB. This study aimed to determine the seroprevalence of anti-H. capsulatum IgG antibody among pulmonary TB patients. This was a sub-study of 306 participants from a prospective cohort pulmonary TB study conducted at seven TB referral hospitals in Indonesia. The study population was presumptive pulmonary TB adult patients who underwent microbiological TB examinations and were categorized as drug-sensitive (DS), drug-resistant (DR), and clinically-diagnosed TB. Anti-H. capsulatum IgG antibody levels at baseline were measured using MVista Histoplasma Ab enzyme immunoassays. Data were summarized using descriptive statistics. Bivariate and multivariate logistic regression analysis were performed to assess factors associated with anti-H. capsulatum IgG antibody positive result. 12.7% (39/306) of pulmonary TB patients were positive for anti-H. capsulatum IgG antibodies (DR-TB patients (15.9%, 18/114), DS-TB (13.0%, 15/115), and clinically-diagnosed TB (7.8%, 6/77)). The median unit value of anti-H. capsulatum IgG antibody for all positive samples was 15.7 (IQR 10.2-28.9) EU. This median unit value was higher in clinically-diagnosed TB patients compared to DS-TB or DR-TB patients (38.1 (IQR 25.6-46.6) EU, 19.7 (IQR 12.3-28.9) EU, and 10.9 (IQR 9.2-15.4), respectively). There were 10 patients (3.3%) with anti-H. capsulatum IgG antibody levels above 30 EU. Factors associated with the anti-H. capsulatum IgG antibody positive result were malignancies (OR 4.88, 95% CI 1.09-21.69, p = 0.037) and cavitary lesions (OR 2.27, 95% CI 1.09-4.70, p = 0.028). Our results provide evidence of exposure to H. capsulatum among pulmonary TB patients in Indonesia. Further studies are needed to provide a comprehensive picture of this fungal disease in other populations and regions to enhance awareness among clinicians and public health officials.

Xpert MTB/RIF Ultra on contaminated liquid cultures for tuberculosis and rifampicin-resistance detection: a diagnostic accuracy evaluation

Xpert MTB/RIF Ultra (Ultra) is a widely used rapid front-line tuberculosis and rifampicin-susceptibility testing. Mycobacterium Growth Indicator Tube (MGIT) 960 liquid culture is used as an adjunct but is vulnerable to contamination. We aimed to assess whether Ultra can be used on to-be-discarded contaminated cultures. We stored contaminated MGIT960 tubes (growth-positive, acid-fast bacilli [AFB]-negative) originally inoculated at a high-volume laboratory in Cape Town, South Africa, to diagnose patients with presumptive pulmonary tuberculosis. Patients who had no positive tuberculosis results (smear, Ultra, or culture) at contamination detection and had another, later specimen submitted within 3 months of the contaminated specimen were selected. We evaluated the sensitivity and specificity of Ultra on contaminated growth from the first culture for tuberculosis (next-available non-contaminated culture result reference standard) and rifampicin resistance (vs MTBDRplus on a later isolate). We calculated potential time-to-diagnosis improvements and also evaluated the immunochromatographic MPT64 TBc assay. Between June 1 and Aug 31, 2019, 36 684 specimens from 26 929 patients were processed for diagnostic culture. 2402 (7%) cultures from 2186 patients were contaminated. 1068 (49%) of 2186 patients had no other specimen submitted. After 319 exclusions, there were 799 people with at least one repeat specimen submitted; of these, we included in our study 246 patients (31%) with a culture-positive repeat specimen and 429 patients (54%) with a culture-negative repeat specimen. 124 patients (16%) with a culture-contaminated repeat specimen were excluded. When Ultra was done on the initial contaminated growth, sensitivity was 89% (95% CI 84-94) for tuberculosis and 95% (75-100) for rifampicin-resistance detection, and specificity was 95% (90-98) for tuberculosis and 98% (93-100) for rifampicin-resistance detection. If our approach were used the day after contamination detection, the time to tuberculosis detection would improve by a median of 23 days (IQR 13-45) and provide a result in many patients who had none. MPT64 TBc had a sensitivity of 5% (95% CI 0-25). Ultra on AFB-negative growth from contaminated MGIT960 tubes had high sensitivity and specificity, approximating WHO criteria for sputum test target product performance and exceeding drug susceptibility testing. Our approach could mitigate negative effects of culture contamination, especially when repeat specimens are not submitted. The European & Developing Countries Clinical Trials Partnership, National Institutes of Health.

Rapid diagnosis of TB using Aptamer-based assays for Mycobacterium tuberculosis antigens in children and adolescents.

Despite advances establishing microbiological evidence of tuberculosis (TB) is still a concern in children due to the limitation of availability of sample and predominance of extrapulmonary TB, there is unmet need for diagnostic tests which are low cost, rapid and sensitive and specific. This study evaluated the utility of aptamer-based assay for detecting mycobacterium tuberculosis antigens HspX and MPT 64 in rapid diagnosis of TB in children up to 18 years of age in a tertiary medical college. A total of 100 children were sequentially enrolled with presumptive pulmonary (n = 52 and extrapulmonary n = 48) TB based on clinico-radiological characteristics. The samples were evaluated with ALISA technique for TB antigens and compared with the results of ZN microscopy, GeneXpert and mycobacterial culture MGIT. The enrolled children had mean age (11.7 + 4.4 years) with both pulmonary (n = 52) and extrapulmonary TB (n = 48). Our study results concluded poor results of smears (11% positivity, sensitivity: 17.7%, NPV: 42.7%) and better of GeneXpert (positivity: 42%, sensitivity of 67.4%, NPV: 65.5%) and culture (positivity 57%, sensitivity 91.9%, NPV 88.3%). HspX antigen by ALISA had comparable results (positivity: 49%, sensitivity: 62.9%; NPV: 54.9%). MPT 64 antigen by ALISA also had similar results (positivity: 45%, sensitivity: 58% and NPV 52, 3%). Sensitivity and specificity were higher in pulmonary TB compared to EPTB for both antigens. HspX antigen assay by ALISA and MPT 64 ALISA over existing microbiological diagnostic methods had additional of 13%. ALISA technique for mycobacterium antigens HspX and MPT 64 was rapid, low-cost test (1-3$/test) high sensitivity and specificity and comparable to currently available methods.

Impact of the use of GeneXpert on TB diagnosis and anti-TB treatment outcome at health facilities in Addis Ababa, Ethiopia in the post-millennium development years.

GeneXpert is an effective and rapid molecular system used for tuberculosis (TB) diagnosis. It is expected to improve the detection rate and treatment outcomes needed to meet the sustainable development goals (SDG) and End TB strategy targets set for 2030. This study aimed to evaluate the impact of GeneXpert on diagnosis and anti-TB treatment outcomes in the post-millennium development goals (MDGs) in the capital city of Ethiopia. Hence, the global priority indicator based on the End TB Strategy for TB treatment success rate was met early in 2018 in Addis Ababa, Ethiopia, which was anticipated to be met by 2025. A retrospective health facilities-based study was conducted in Addis Ababa, Ethiopia. Records of all TB cases diagnosed and treated in selected health facilities from January 1st, 2015 to December 31st, 2018 were reviewed and included in the study. Data analysis of descriptive and inferential statistics was conducted using SPSS version 20. The reviewed records have shown that a total of 45,158 presumptive pulmonary TB (PTB) cases had accessed TB diagnosis services. Of which, 28.9% (13072/45158) were tested by AFB microscopy and 71.1% (32086/45158) were tested by GeneXpert. During the study period, the coverage of Xpert MTB/RIF testing increased to 94.9% in 2018 compared to 1.6% in 2015. The number of presumptive PTB cases tested with the GeneXpert system showed a significant increase compared to smear microscopy. The odds of positivity were detected in males compared to females. The odds of detecting TB cases were much higher among study participants aged 15-44 years compared to younger than 15 years. Treatment success rate showed a relative improvement each year between 2015 and 2018 with a mean of 92.6%. Reduced odds of treatment successes were observed in age categories older than 35 years, and in TB/HIV co-infected patients. Increased odds of treatment successes were reported in the years between 2016 and 2018 compared to 2015. Scaling up the Xpert MTB/RIF assay as a point-of-care test for presumptive TB cases in resource-limited settings would have a significant impact to meet the SDG and End TB strategy both in TB detection and treatment success rates.

Investigating Metabolic and Molecular Ecological Evolution of Opportunistic Pulmonary Fungal Coinfections: Protocol for a Laboratory-Based Cross-Sectional Study.

Fungal-bacterial cocolonization and coinfections pose an emerging challenge among patients suspected of having pulmonary tuberculosis (PTB); however, the underlying pathogenic mechanisms and microbiome interactions are poorly understood. Understanding how environmental microbes, such as fungi and bacteria, coevolve and develop traits to evade host immune responses and resist treatment is critical to controlling opportunistic pulmonary fungal coinfections. In this project, we propose to study the coexistence of fungal and bacterial microbial communities during chronic pulmonary diseases, with a keen interest in underpinning fungal etiological evolution and the predominating interactions that may exist between fungi and bacteria. This is a protocol for a study aimed at investigating the metabolic and molecular ecological evolution of opportunistic pulmonary fungal coinfections through determining and characterizing the burden, etiological profiles, microbial communities, and interactions established between fungi and bacteria as implicated among patients with presumptive PTB. This will be a laboratory-based cross-sectional study, with a sample size of 406 participants. From each participant, 2 sputa samples (one on-spot and one early morning) will be collected. These samples will then be analyzed for both fungal and bacterial etiology using conventional metabolic and molecular (intergenic transcribed spacer and 16S ribosomal DNA-based polymerase chain reaction) approaches. We will also attempt to design a genome-scale metabolic model for pulmonary microbial communities to analyze the composition of the entire microbiome (ie, fungi and bacteria) and investigate host-microbial interactions under different patient conditions. This analysis will be based on the interplays of genes (identified by metagenomics) and inferred from amplicon data and metabolites (identified by metabolomics) by analyzing the full data set and using specific computational tools. We will also collect baseline data, including demographic and clinical history, using a patient-reported questionnaire. Altogether, this approach will contribute to a diagnostic-based observational study. The primary outcome will be the overall fungal and bacterial diagnostic profile of the study participants. Other diagnostic factors associated with the etiological profile, such as incidence and prevalence, will also be analyzed using univariate and multivariate schemes. Odds ratios with 95% CIs will be presented with a statistical significance set at P<.05. The study has been approved by the Mbarara University Research Ethic Committee (MUREC1/7-07/09/20) and the Uganda National Council of Science and Technology (HS1233ES). Following careful scrutiny, the protocol was designed to enable patient enrollment, which began in March 2022 at Mbarara University Teaching Hospital. Data collection is ongoing and is expected to be completed by August 2023, and manuscripts will be submitted for publication thereafter. Through this protocol, we will explore the metabolic and molecular ecological evolution of opportunistic pulmonary fungal coinfections among patients with presumptive PTB. Establishing key fungal-bacterial cross-kingdom synergistic relationships is crucial for instituting fungal bacterial coinfecting etiology. ISRCTN Registry ISRCTN33572982; https://tinyurl.com/caa2nw69. DERR1-10.2196/48014.

Comparison of Xpert MTB/RIF Ultra Results of Stool and Sputum in Children with Presumptive Tuberculosis in Southern Ethiopia.

The introduction of stool as a readily obtainable sample and the recently developed simple one-step (SOS) stool processing method on Xpert MTB/RIF Ultra (Xpert Ultra) offer an opportunity for TB diagnosis in children. We conducted this study in secondary health facilities in Ethiopia, which are the first-level referral facilities for childhood TB diagnosis and treatment, with the aim to determine if stool-based TB diagnosis can be performed with a reasonable level of concordance with sputum tests using Xpert MTB/RIF Ultra. Eligible children 0-14 years old with presumptive pulmonary TB were asked to provide stools in addition to routinely requested sputum samples. We determined the level of agreement between the stool and sputum test results. Of the 373 children included in the study, 61% were <5 years of age and 56% were male. Thirty-six children (9.7%) were diagnosed with TB, and all started treatment. The rate of concordance between stool and sputum was high, with a kappa value of 0.83 (p < 0.001). There were more Xpert Ultra positive results on stool (n = 27 (7.2%)) than on sputum/NGA (n = 23 (6.2%)). Laboratories in secondary hospitals can perform stool-based TB diagnosis in children, with high concordance between stool and sputum test results reaffirming the applicability of the SOS stool method.

Xpert MTB/RIF Ultra Assay Using Stool: an Effective Solution for Bacilli Identification from Adult Pulmonary Tuberculosis Suspects without Expectorated Sputum.

This study evaluated the diagnostic performance of stool-based Xpert MTB/RIF Ultra assay (Xpert-Ultra, Cepheid, USA) against other tests using respiratory tract specimens (RTS) and stool for diagnosing adult pulmonary tuberculosis. A prospective study on patients with presumptive pulmonary tuberculosis was conducted in Beijing Chest Hospital from June to November 2021. The smear test, MGIT960 liquid culture, and Xpert MTB/RIF (Xpert, Cepheid, USA) were performed simultaneously on RTS, and smear, culture Xpert, and Xpert-Ultra were performed simultaneously using stool. Patients were grouped based on the outcomes of RTS examination and other tests. In total, 130 eligible patients were enrolled that included 96 pulmonary tuberculosis and 34 non-TB patients. The sensitivity of smear, culture, Xpert, and Xpert-Ultra using stool was 10.96%, 23.28%, 60.27%, and 79.45%, respectively. The specificities of Xpert and Xpert-Ultra using RTS and stool were all 100% (34/34). Notably, all five confirmed cases detected by bronchoalveolar lavage fluid (BALF) examination yielded Xpert-Ultra positive outcomes with the stool specimens. Xpert-Ultra assay on stool sample harbors comparable sensitivity with Xpert on RTS. Thus, the Xpert-Ultra testing on stool specimens could be a very promising and practical strategy to improve pulmonary tuberculosis (PTB) diagnosis, especially among patients who could not expectorate sputum. IMPORTANCE This study is aimed at assessing the value of Xpert MTB/RIF Ultra (Xpert-Ultra) in PTB on stool in adult in low HIV settings and Xpert-Ultra assay on stool sample harboring comparable sensitivity with Xpert MTB/RIF on respiratory tract specimens. Although the yield in stool samples by Xpert-Ultra is lower than RTS, it may be useful in detecting disease in presumptive TB patients who cannot expectorate sputum and are not open to BALF collection. In addition, Xpert-Ultra with a "trace call" on stool in adult was highly supportive of PTB.

Prevalence of Hepatitis B Virus, Human Immune Deficiency Virus and Associated Risk Factors Among Individuals with Presumptive Pulmonary Tuberculosis Attending at Saint Peter's Specialized Hospital, Addis Ababa, Ethiopia.

Hepatitis B virus (HBV), human immunodeficiency virus (HIV) and tuberculosis are the causes of widely spread infectious disease, especially in resource-limited countries. The extent of HBV infection and its contributing factors among people with suspected pulmonary tuberculosis (PTB) were not adequately addressed. To assess the prevalence of HBV, HIV & their associated risk factors and the magnitude of TB among individuals with presumptive pulmonary tuberculosis attending at St. Peter's Specialized Hospital, Addis Ababa, Ethiopia. A cross-sectional study was conducted among 387 individuals with presumptive PTB from October to December 2020. A standard questionnaire was used to collect socio-demographic data and associated risk factors. Sputum samples were analyzed by GeneXpert, Florescent Microscopy and Ziehl-Nelson staining technique. HBsAg test was carried out using Murex Version 3 ELISA test kit from serum/Plasma samples,HIV testing was performed by rapid HIV test kits and data were analyzed using SPSS version 23. The mean age of study participants was 44.2 years. Overall, 14 (3.6%), 28 (7.2%) and 37 (9.6%) of them were positive for HBV, HIV & TB, respectively. Only single patient was HBV-HIV co-infected (0.3%). The TB-HIV co-infection was identified in 6 (1.6%). In multivariate analysis, being partner separated, alcohol consumption, body piercing and having multiple sexual partners were significantly associated with HBV infection. Having a spouse, who is divorced, widowed, sharing scissors, alcohol consumption and contact with multiple sexual partners also significantly associated with HIV infection. This study showed that HBV, HIV and TB are still public health issues that need awareness and health education on the risky behaviors and transmission of HBV, HIV & TB among individuals with presumptive TB suspects. Further large-scale study is necessary.

UMOYA: a prospective longitudinal cohort study to evaluate novel diagnostic tools and to assess long-term impact on lung health in South African children with presumptive pulmonary TB—a study protocol

BackgroundDespite a high paediatric tuberculosis (TB) burden globally, sensitive and specific diagnostic tools are lacking. In addition, no data exist on the impact of pulmonary TB on long-term child lung health in low- and middle-income countries. The prospective observational UMOYA study aims (1) to build a state-of-the-art clinical, radiological, and biological repository of well-characterised children with presumptive pulmonary TB as a platform for future studies to explore new emerging diagnostic tools and biomarkers for early diagnosis and treatment response; and (2) to investigate the short and long-term impact of pulmonary TB on lung health and quality of life in children.MethodsWe will recruit up to 600 children (0–13 years) with presumptive pulmonary TB and 100 healthy controls. Recruitment started in November 2017 and is expected to continue until May 2023. Sputum and non-sputum-based samples are collected at enrolment and during follow-up in TB cases and symptomatic controls. TB treatment is started by routine care services. Intensive follow-up for 6 months will allow for TB cases to retrospectively be classified according to international consensus clinical case definitions for TB. Long-term follow-up, including imaging, comprehensive assessment of lung function and quality of life questionnaires, are done yearly up to 4 years after recruitment.DiscussionThe UMOYA study will provide a unique platform to evaluate new emerging diagnostic tools and biomarkers for early diagnosis and treatment response and to investigate long-term outcomes of pulmonary TB and other respiratory events on lung health in children.

Burden of Mycobacterium tuberculosis and Associated Factors among Presumptive Extra pulmonary Tuberculosis Patients from Selected Health Facilities, Addis Ababa, Ethiopia

BackgroundExtra pulmonary tuberculosis (EPTB) accounts for a significant proportion of tuberculosis (TB), a devastating disease of public health concern. The complexity of the cases, the involvement of many organs, resource constraints, and concerns regarding drug resistance make disease diagnosis and treatment difficult. This study aimed to determine the burden of tuberculosis and associated factors among presumptive EPTB patients in selected hospitals in Addis Ababa. Material and methodsA cross-sectional study was conducted from February to August 2022 in selected public hospitals in Addis Ababa. Those who attended the hospitals and were presumptively diagnosed as EPTB patient were included in the study. Sociodemographic and clinical data were collected using a semistructured questionnaire. The GeneXpert MTB/RIF assay, Mycobacterium Growth Indicator Tube (MGIT) culture, and solid culture using Löwenstein–Jensen (LJ) medium were used. The data were entered and analyzed using SPSS version 23, and a p-value ≤ 0.05 was considered as statistically significant. ResultsFrom a total of 308 participants enrolled in this study, the measured burdens of extrapulmonary tuberculosis using the Xpert MTB/RIF assay, liquid culture, and solid culture were 54 (17.5%), 45 (14.6%), and 39 (12.7%), respectively. In this study, sex, contact history with known TB cases, having a purulent type of aspirate, and being HIV positive had statistically significant associations with EPTB. ConclusionsThe burden of extrapulmonary tuberculosis among presumptive extrapulmonary tuberculosis cases was found to be significant. Sex, contact history with a known TB case, having apurulent type of aspirate, and being HIV positive were found to be associated with extrapulmonary tuberculosis infection. Strict adherence to the national tuberculosis diagnosis and treatment guidelines is important, while the true burden of the disease should be ascertained using standard diagnostic tests for better prevention and control interventions.

A Study on Sputum Induction in the Diagnosis of Smear Negative or Sputum -Scarce Presumptive Tuberculosis in HIV Patients in A Tertiary Care Center

Background: HIV infection and TB are two major public health problems in most of the developing countries including India. TB also the most common opportunistic infection seen in HIV infected patients in India 1,2. Tuberculosis is a significant increase in the worldwide incidence of TB which is contributed majorly by HIV infection. AIM: To study the role of Sputum Induction to aid in the diagnosis of Smear Negative or Sputum Scare Presumptive Pulmonary Tuberculosis in adults with HIV. Material &amp; Methods: Prospective hospital based observational study. The present study was conducted in the department of TB &amp; Respiratory medicine, Osmania Medical College, Hyderabad. The subjects of the study were selected among the HIV positive with Presumptive Pulmonary Tuberculosis patients who visited the outpatient department or had been admitted in our hospital who agreed for voluntary participation. A total of 50 Presumptive Pulmonary Tuberculosis with HIV co- infection were taken as sample size. Results: The majority of cases (38 %) were in the age group of 31-40 yrs. Mean age of the study group population is 39.76 ± 9.24. The predominant symptom in the present study was loss of appetite. Out of 50 patients 34% (17 patients) were known Diabetic and 10% (5 patients) were known Hypertensive. Most of the patients in my study are smokers (40%). The mean CD4 count in the present study is 182.68. Majority (72%) of patients in the present study did not have previous history of TB. On General examination majority of the patients had Lymphadenopathy. Out of 45 adequate Induced sputum cases, 89% (40 cases) were Negative for Sputum AFB and whereas 11% (5 cases) were Positive for Sputum AFB. Conclusion: Sputum induction is a safe, simple and valuable procedure to obtain adequate sputum samples in suspected cases of pulmonary tuberculosis and can obviate the need for much sophisticated and invasive procedures like bronchoscopy. Sputum induction improves the diagnostic yield for AFB in patients unable to expectorate adequate sputum sample.

Truenat MTB assays for pulmonary tuberculosis and rifampicin resistance in adults

Objectives This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows: To determine the diagnostic accuracy of Truenat assays (MTB, MTB Plus, and MTB RIF Dx) for detecting pulmonary tuberculosis and rifampicin resistance in adults with presumptive pulmonary tuberculosis. Secondary objectives To compare the diagnostic accuracy of Truenat assays (MTB, MTB Plus, and MTB RIF Dx) with that of Xpert MTB/RIF Ultra for the detection of pulmonary tuberculosis and rifampicin resistance in adults with presumptive pulmonary tuberculosis. To summarize the frequency of non‐determinate Truenat results. To determine the diagnostic accuracy of Truenat after repeat testing in people with non‐determinate test results. To investigate potential sources of heterogeneity in the diagnostic accuracy of Truenat for the detection of pulmonary tuberculosis in relation to covariates such as the setting where the index tests were performed, HIV status, previous history of tuberculosis, and sputum smear test status. To investigate heterogeneity in the diagnostic accuracy of Truenat for detecting rifampicin resistance in relation to sputum smear status.

Rifampicin resistant Mycobacterium tuberculosis and associated factors among presumptive pulmonary tuberculosis patients in Mogadishu, Somalia.

Multi-drug resistant Mycobacterium tuberculosis is a growing public health problem in developing countries including Somalia. Although, the prevalence of multi-drug resistant tuberculosis among new and retreated cases is high, data on GeneXpert- Mycobacterium tuberculosis/rifampicin-resistant assay, which is a surrogate marker for multidrug resistance, is not well explored in Mogadishu. To determine the prevalence of rifampicin-resistant Mycobacterium tuberculosis and its associated factors among presumptive pulmonary tuberculosis patients visiting tuberculosis centers in Mogadishu, Somalia. A multicenter cross-sectional study was conducted in three tuberculosis treatment centers from March 12 to April 30, 2021. Laboratory professionals collected sputum sample consecutively from presumptive pulmonary tuberculosis participants and performed a GeneXpert assay to determine the rifampicin resistance. Socio-demographic and clinical data were collected using structured questionnaire. Logistic regression analyses were performed to assess factors associated with rifampicin resistance using an adjusted odds ratio at a 95% confidence interval. Statistical significance was considered at a p-value of less than 0.05. A total of 370 presumptive tuberculosis suspects were included; of whom 58.4% were females and the mean age of the participants was 44.3 ± 14 years. Mycobacterium tuberculosis was detected in 63 (17%) (95% confidence interval = 13.2-20.8) suspects. Of these the prevalence of rifampicin-resistant Mycobacterium tuberculosis was 35% (95% confidence interval = 30.2-39.8). Anti-tuberculosis treatment history (adjusted odds ratio = 4.1; 95% confidence interval = 1.91-6.75), monthly income less than $100 USD (adjusted odds ratio = 2.2; 95% confidence interval = 1.77-5.98) and being diagnosed with Asthma (adjusted odds ratio = 2.63; 95% confidence interval = 1.3-7.3) were significantly associated with rifampicin-resistant tuberculosis. A considerable proportion of rifampicin-resistant tuberculosis is reported in these study settings. The strong association between multidrug resistance tuberculosis and patients' retreatment history of tuberculosis, low income, and co-morbidity with asthma highlights the need for more efforts in tuberculosis treatment and monitoring programs to limit the emergence of multi-drug resistant strain in the study areas.

Association Between Cycle Threshold Value of Cartridge-Based Nucleic Acid Amplification Test and Clinical Severity of Pulmonary Tuberculosis: A Cross-sectional Study

Introduction: Tuberculosis (TB) is a major global health problem caused by Mycobacterium tuberculosis (MTB). The National Tuberculosis Elimination Programme (NTEP) emphasises early diagnosis and treatment of TB cases. The Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) is a semi-automated molecular assay that rapidly detects MTB Deoxyribonucleic Acid (DNA) and Rifampicin (RIF) resistance-associated mutations using Real-Time Polymerase Chain Reaction (RT-PCR). Aim: This cross-sectional study aims to assess the association between the Cycle Threshold (Ct) value of CBNAAT and the clinical severity of Pulmonary Tuberculosis (PTB). Materials and Methods: The study was conducted at the Department of Respiratory Medicine, Navodaya Medical College Hospital and Research Centre-Raichur, from January 2020 to July 2021. A sample size of 106 participants, aged ≥18 years and meeting the NTEP guidelines for presumptive PTB cases, were enrolled. Participants underwent chest radiography, sputum smear microscopy for Acid-Fast Bacilli (AFB), and CBNAAT testing. Clinical severity of PTB was categorised as mild, moderate, or severe using the Bandim TB score. Data was entered into Microsoft Excel 2017, and statistical analysis was performed using SPSS version 23. Descriptive statistics, frequencies, percentages, means, and standard deviations were calculated, and the chi-square test was utilised to assess associations between qualitative variables. Results: Among the participants, the majority (55.7%, n=59) had moderate clinical severity. Of these, 12.3% (n=13) had high CBNAAT Ct values, 20.8% (n=22) had medium Ct values, 11.3% (n=12) had low Ct values, and 11.3% (n=12) had very low Ct values. A total of 31.1% (n=33) had severe clinical severity, with 13.2% (n=6) having high Ct values, 12.3% (n=13) having medium Ct values, and 6.6% (n=7) each having low and very low Ct values. Additionally, 13.2% (n=14) had mild clinical severity, with 0.9% (n=1) having high Ct values, 3.8% (n=4) having medium Ct values, 5.7% (n=6) having low Ct values, and 2.8% (n=3) having very low Ct values. The chi-square value was 4.697, with a p-value of 0.58. Conclusion: There is no association between the Ct value of CBNAAT and the clinical severity of PTB.

High proportion of RR-TB and mutations conferring RR outside of the RRDR of the rpoB gene detected in GeneXpert MTB/RIF assay positive pulmonary tuberculosis cases, in Addis Ababa, Ethiopia.

Globally, TB is the leading cause of infectious disease morbidity and mortality with many diagnostic uncertainties. Access to affordable and rapid diagnostics remained a major challenge for many developing countries which bear the greatest burden of TB delaying the initiation time to treatment. This study aimed to assess the GeneXpert MTBRIF assay probe utility for the detection of pulmonary TB and Rifampicin-resistant TB cases in Addis Ababa, Ethiopia. A cross-sectional study was performed from October 2019 to July 2020 in Saint Peter TB Specialized Hospital in Addis Ababa metropolitan area, Ethiopia. This study enrolled 216 clinically suspected new presumptive pulmonary TB cases confirmed by GeneXpert MTB/RIF Assay. Sociodemographic and clinical characteristics were captured using a structured tool. Data were entered in Microsoft Excel 2019, checked for inconsistency, cleaned promptly, and exported to IBM SPSS Statistics for Windows, Version 26.0. Armonk, N.Y: IBM Corp, the USA for analysis. Descriptive analysis and binary and multivariate logistics regression were performed and all statistical significance was determined at a 95% confidence level. The majority of the study participants, 55.1% [119/216] were males aged 6-80 years. The prevalence of RR MTB was 11.11% [24/216]. A higher proportion of RR TB was found in female patients [54.2%, 13/24], in patients in the age group of 30-50 years [45.8%, 11/24], in married individuals [62.5%, 15/24], in persons whose residence is urban [79.2%, 19/24], in persons who had a previous history of TB symptoms [100%, 24/24], in persons who had a history of contact with active and LTBI [33.3%, 8/24], and in persons who had a history of HIV and IDUs [41.7%, 10/24]. Occupation (AOR 22.868, 95% CI 1.655-316.022, p = 0.019), history of previous PTB+ (AOR 4.222, 95% CI 1.020-17.47, p = 0.047), and history of HIV and IDUs (AOR 4.733, 95% CI 1.416-15.819, p = 0.012) were independent predictors associated with RR-TB emergence. The commonest mutation 62.5% [15/24] was found in probe E (codons 529-533) region. There was no mutation associated with probe A (codons 507-511), probe B (codons 511-518), and probe C (codons 518-523) regions, as well as no combination of missed probes, was revealed. However, 12.5% [3/24] of RR TB patients were found without unidentified missed probe types detected outside of the RRDR. The delta Ct max was >4.0 and the highest proportion of 35.6% [77/216] RR TB was detected in samples of medium DNA load. The proportion of RR-TB we observed in this study was high. Similarly, a higher proportion of RR TB was detected outside of the RRDR. Moreover, a significant number of the GeneXpert MTB/RIF Assay probes were identified as unhybridized and this critical observation would mean that most of the probes had no or minimal utility in this geographical region. This calls for further studies to uncover mutation in the rpoB gene conferring RR and reshape TB triage and definite diagnostic algorithm in Ethiopia.

Characteristics of Drug-sensitive and Drug-resistant Tuberculosis Cases among Adults at Tuberculosis Referral Hospitals in Indonesia.

As Indonesia's rifampin resistance testing rates are lower than global testing rates per the 2020 WHO global tuberculosis (TB) report, prevalence of multidrug-resistant TB may be underestimated. Our study aimed to evaluate prevalence and patterns of TB drug resistance (DR) within Indonesia. We conducted a cross-sectional analysis of baseline data collected from 2017-2018 as part of a cohort study of adults with presumed pulmonary TB at 7 DR-TB referral hospitals in Indonesia. Bacteriological examinations (acid-fast bacilli, GeneXpert, sputum culture) and drug-susceptibility testing were performed following the guidelines of the National TB Program. Of 447 participants with complete bacteriological examinations, 312 (69.8%) had positive sputum cultures for Mycobacterium tuberculosis. The proportion of MDR and pre-extensively drug-resistant was higher in previously treated compared with newly diagnosed participants (52.5% [73/139] versus 15% [26/173]). Compared with drug-sensitive case, drug-resistant TB was associated with cavities. Given the difference between rates of DR in TB referral hospitals from our study compared with the WHO survey in 2019 that showed 17.7% and 3.3% DR among previously treated and newly diagnosed participants globally, further characterization of Indonesia's TB epidemiology in the general population is needed. Strategies, including public policies to optimize case finding, strengthen capacity for resistance testing, and prevent loss to follow-up will be critical to reduce the burden of TB in Indonesia.

Clinical utility of C-reactive protein-based triage for presumptive pulmonary tuberculosis in South African adults

BackgroundIdentification of an accurate, low-cost triage test for pulmonary TB among people presenting to healthcare facilities is an urgent global research priority. We assessed the diagnostic accuracy and clinical utility of C-reactive protein (CRP) for TB triage among symptomatic adult outpatients, irrespective of HIV status. MethodsWe prospectively enrolled adults reporting at least one (for people with HIV) or two (for people without HIV) symptoms of cough, fever, night sweats, or weight loss at two TB clinics in Cape Town, South Africa. Participants provided sputum for culture and Xpert MTB/RIF Ultra. We evaluated the diagnostic accuracy of CRP (measured using a laboratory-based assay) against a TB-culture reference standard as the area under the receiver operating characteristic curve (AUROC), and sensitivity and specificity at pre-specified thresholds. We assessed clinical utility using decision curve analysis and benchmarked against WHO recommendations. ResultsOf 932 included individuals, 255 (27%) had culture-confirmed pulmonary TB and 389 (42%) were living with HIV. CRP demonstrated an AUROC of 0·80 (95% confidence interval 0·77–0·83), with sensitivity 93% (89–95%) and specificity 54% (50–58%) using a primary cut-off of ≥10 mg/L. Performance was similar among people with HIV to those without. In decision curve analysis, CRP-based triage offered greater clinical utility than confirmatory testing for all up to a number willing to test threshold of 20 confirmatory tests per true positive pulmonary TB case diagnosed (threshold probability 5%). If it is possible to perform more confirmatory tests than this, a ‘confirmatory test for all’ strategy performed better. ConclusionsCRP achieved the WHO-defined sensitivity, but not specificity, targets for a triage test for pulmonary TB and showed evidence of clinical utility among symptomatic outpatients, irrespective of HIV status. FundingSouth African Medical Research Council, EDCTP2, Royal Society Newton Advanced Fellowship, Wellcome Trust, National Institute of Health Research, Royal College of Physicians.

Diagnostic Performance of Multiplex PCR for Detection of Mycobacterium tuberculosis Complex in Presumptive Pulmonary Tuberculosis Patients and Its Utility in Smear Negative Specimens.

Objective The primary objective of this study was to assess the diagnostic performance of multiplex polymerase chain reaction (mPCR) for the detection of Mycobacterium tuberculosis complex (MTBC) in presumptive pulmonary TB patients, in the setting of a tertiary level teaching hospital in central India, in comparison to liquid culture using BACTEC mycobacteria growth indicator tubes (MGIT) 960 TB system as the gold standard. The secondary objective was to assess the performance of mPCR for Ziehl Neelsen smear negative samples and ascertain the utility of this assay in smear negative samples. Materials and Methods Sputum or bronchoalveolar lavage samples were collected from patients who were adults, aged 18 years or older, presenting with presumptive pulmonary TB, and subjected to three microbiological investigations, that is, Ziehl Neelsen staining, mycobacterial culture using mycobacterial growth indicator tubes in the BD BACTEC MGIT 960 instrument, and the mPCR. Statistical Analysis For statistical analysis, 2 × 2 contingency tables were prepared and analyzed separately for all samples and for smear-negative samples using GraphPad and MedCalc tools. Sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of mPCR were calculated by taking MGIT culture as the reference standard. Results For all samples ( n = 114), sensitivity of mPCR for the detection of (MTBC) was 93.48% (95% confidence interval [CI]: 82.10-98.63%), specificity was 95.59% (95% CI: 87.64-99.08%), positive predictive value (PPV) was 93.48% (95% CI: 82.54-97.75%), and NPV was 95.59% (95% CI: 87.87-98.48%). For smear negative samples ( n = 80), sensitivity was 80.00% (95% CI: 51.91-95.67%), specificity was 98.46% (95% CI: 91.72-99.96%), PPV was 92.31% (95% CI: 62.80-98.84%), and NPV was 95.52% (95% CI: 88.57-98.33%). Conclusion In this study, we were able to demonstrate the good performance characteristics of the mPCR for the detection of MTBC from clinical samples of patients with presumptive pulmonary tuberculosis, with MGIT liquid culture as the reference standard. It may be concluded that mPCR can be considered equivalent to MGIT culture in terms of clinical decision making and yield of positivity, owing to the good sensitivity and specificity for the detection of MTBC.