Acid-fast Bacilli Staining Research Articles

Synthetic Electrospun Fiber Matrix May Resemble Fungal Hyphae Over the Course of Tissue Regeneration: A Retrospective Review

Peripheral soft tissue resections offer unique wound care challenges, often leaving large surgical deficits that are slow to heal and prone to infection. Musculoskeletal surgeons have taken to utilizing a synthetic electrospun fiber matrix (SEFM) to aid in soft tissue repair. SEFM is an engineered, fully resorbable, electrospun fiber matrix engineered to mimic human extracellular matrix supporting cell ingrowth, retention, and differentiation. In addition, in vitro studies have shown SEFM to be effective at inhibiting growth of the most common bacterial and fungal organisms found in surgical site infections. However, little is reported about the histologic features of intact and resorbing SEFM in vivo. Upon investigation, it was observed that the SEFM may resemble fungal hyphae during its 1-3 week degradation via hydrolysis. Special stains for fungi and acid-fast bacilli display positivity in SEFM, further complicating precise diagnosis. Although these specimens should still be carefully evaluated for fungal organisms, it is important to note these potential pitfalls to avoid misdiagnosis, avoid the premature removal of SEFM, and avoid initiation of inappropriate anti-fungal therapy.

Dual infection of maxillary sinus masquerading as a malignant lesion; A rare presentation

Primary sinonasal tuberculosis is a rare form of TB even in developing countries where TB is prevalent and invasive mycotic infection is more common in immunocompromised patients. It is unusual to have a dual infection with tuberculosis and mycosis in the maxillary region mimicking a neoplastic process and causing bone erosion. A 49-year old male presented with 2-year history of left-sided facial swelling. On microscopic examination, epithelioid cell granulomas, chronic inflammatory infiltrate, macrophages, giant cells, and focal necrosis were seen. Ziehl Neelsen staining for acid-fast bacilli with 20% H2SO4 was positive. Fungal hyphae were also seen in the sections examined. Special stains (Periodic acid-Schiff and Grocott’s methenamine silver stain) for fungal hyphae were positive. Mycosis and tuberculosis should always be considered in the differential diagnosis of maxillary lesions or sinusitis.

Suppurative Granulomatous Osteomyelitis with Microcystic Changes Due to Mycobacterium chelonae- abscessus Complex

Abstract Introduction/Objective Mycobacterium chelonae and Mycobacterium abscessus are rapidly growing non-tuberculous mycobacterium found in soil and water, and represent rare causes of skin and soft tissue infection. Treatment typically involves an extended course of antimicrobial therapy and occasionally surgical debridement. Previous reports have described a distinctive pattern of suppurative granulomatous inflammation with microcystic changes in skin biopsies; however, the morphologic changes of M. chelonae-abscessus complex as a cause of osteomyelitis have not been well-documented in the literature. Methods/Case Report We searched our database from 2013 to 2024 for bone samples diagnosed as granulomatous inflammation in which M. chelonae or M. abscessus were identified on concurrent microbiology studies. Patient demographics, risk factors for infection, and treatment data were collected. Results (if a Case Study enter NA) Three patients with culture- or PCR-confirmed M. chelonae (2) or M. abscessus (1) were identified. All infections involved bones of the distal extremities. Patients were 57 years and older with risk factors for infection that included: diabetes (1), intravenous drug use (1), and long-term immunosuppressive therapy (1). All patients presented with osteomyelitis refractory to antibiotic therapy for which bone biopsy, bone resection, or amputation was performed. All cases showed suppurative granulomatous inflammation with microcystic changes. Cystic spaces were markedly enriched for acid-fast bacilli on Fite and/or Ziehl-Neelsen stains. In two patients, the antimicrobial regimen was changed as a result of the pathologic findings and microbiologic testing that provided additional information about speciation and susceptibilities. Conclusion Suppurative granulomatous inflammation has a broad differential that includes blastomycosis, sporotrichosis, cat scratch disease, non-tuberculous mycobacterial infection, and granulomatosis with polyangiitis, for which there are substantial treatment differences. When this pattern of microcystic suppurative granulomatous inflammation is encountered, it is important to perform special stains for acid-fast bacilli, particularly when seen in distal extremity lesions from patients with infections that are refractory to empiric antibiotic therapy.

A rare case of intestinal obstruction due to tuberculosis.

A 19-year-old previously healthy patient presented with severe abdominal pain. A contrast-enhanced CT scan identified ileal obstruction and lower left lung lobe changes suggestive of an inflammatory process. Diagnostic laparoscopy revealed ileal distension, hyperemia, and whitish nodules on the serosa. Acid-fast bacilli staining was positive, confirming Mycobacterium tuberculosis infection. The patient improved with a tuberculosis regimen. Intestinal TB often affects the ileocecal area and presents with symptoms like abdominal pain and obstruction. Diagnosis is confirmed by AFB staining, and treatment mirrors pulmonary TB, though surgery may be needed for complications.

Clinically Suspicious Cases of Hansen's Disease at a Tertiary Care Hospital in South India: A Clinicopathological Study.

Background and objective Hansen's disease, also known as leprosy, is a chronic granulomatous condition caused by Mycobacterium leprae, primarily affecting the skin and peripheral nerves. The disease has a wide spectrum of clinical and histopathological manifestations, often mimicking other inflammatory and infectious conditions. This variability poses significant challenges in its early diagnosis and management. Aligning clinical suspicion with histopathological evidence is critical for effective treatment and control of transmission. This study was designed to explore the concordance between clinical impressions and histopathological diagnoses and to understand the diagnostic utility of various histopathological techniques. We aimed to establish and correlate the histopathological types of leprosy with clinical presentations. We also sought to determine the extent to which different histopathological techniques, including special stains, can corroborate with clinical types, thereby enhancing diagnostic precision. Materials and methods This was a hospital-based, retrospective study of clinically suspicious cases of leprosy at a tertiary care hospital in South India. A total of 100 cases of various age groups were identified and included in the study. All cases underwent skin biopsy with samples subjected to routine hematoxylin and eosin (H&E) staining and acid-fast bacilli (AFB) staining for the detection oflepra bacilli. Results Among the 100 clinically suspicious cases of leprosy, 50were histopathologically confirmed as leprosy and 50were categorized as non-specific dermatitis. Among the 50 histologically confirmed cases of leprosy, the most common type was lepromatous leprosy (LL) (38%) followed by borderline tuberculoid (BT) (30%) leprosy.Modified AFBstain was positive in 21 cases and was instrumental in confirming the suspected cases of leprosy. The overall correlation between the clinical and histopathological diagnosis was significant, with the highest correlation noted in LL cases. Conclusions Our findings underscorethe complexity of diagnosing leprosy due to its varied clinical and pathological presentations. Despite a high overall concordance rate, the discrepancies between clinical impressions and histopathological findings observed highlight the need for a multidimensional diagnostic approach. Incorporating a combination of clinical assessment, routine histology, and special staining can enhance diagnostic accuracy, leading to better patient management and outcomes.

ISOLATED TUBERCULOSIS OF PAROTID GLAND:A COMMON DISEASE AT AN UNCOMMON LOCATION WITH REVIEW OF LITERATURE

Tuberculosis infection is a common health problem in developing countries like India which is caused by Mycobacterium tuberculosis (MTB). It commonly affects the pulmonary system. Although it can affect any organ of the body but salivary glands especially the parotid gland arethe rarest entity that is involved in tuberculosis. Less than 200 cases have been reported in literature till now and mostly diagnosed in post-parotidectomy specimens. Generally, it presents with a painless growing mass and hence, its clinical diagnosis is challenging and may be misdiagnosed as it can mimic parotid gland neoplasm on physical examination. Radiological investigations such as ultrasonography (USG) and computed tomography (CT) are not much beneficial. In such cases, fine needle aspiration cytology (FNAC) is the preliminary step for the workup of the patients. Histologically diagnosis is confirmed by the presence of well-formed epithelioid cell granuloma and acid-fast bacilli (AFB) stain is positive for tubercular bacilli. Here we report a case of tubercular parotitis in a 50-year-old female diagnosed on histopathological examination and patient treated with anti-tubercular therapy (ATT) successfully.

Diagnostic accuracy of GeneXpert in the diagnosis of spinal tuberculosis: A systematic review and meta-analysis.

Tuberculosis remains a significant global health issue, with spinal tuberculosis being a severe form of extrapulmonary tuberculosis. Despite the high morbidity associated with spinal tuberculosis, effective and rapid diagnostic methods are limited. The aim of this study was to evaluate the diagnostic accuracy of the GeneXpert compared to other microbiological methods in diagnosing spinal tuberculosis. A systematic review and meta-analysis were conducted following the PRISMA guidelines. Six databases (PubMed, Scopus, EBSCO, EMBASE, ScienceDirect, and Cochrane Central) were searched for relevant studies as of August 31, 2023. Studies were selected based on predefined inclusion criteria, focusing on patients diagnosed with spinal tuberculosis and comparing GeneXpert to microbiological culture, acid-fast bacilli (AFB) staining, and polymerase chain reaction (PCR). Two authors independently performed data extraction and quality assessment, and the meta-analysis was conducted using Meta-DiSc 2.0. Fourteen studies comprising retrospective cohort, prospective cohort, and cross-sectional designs were included. GeneXpert demonstrated a pooled sensitivity of 92% (85-96%) and specificity of 71% (51-86%) compared to culture. AFB smear had the highest specificity at 80% (70- 88%) but the lowest sensitivity at 27% (20-35%). The PCR had sensitivity and specificity of 83% (67-92%) and 58% (31-81%), respectively. Substantial heterogeneity was noted across the studies. This study highlighted that GeneXpert had high sensitivity and moderate specificity in diagnosing spinal tuberculosis, making it an alternative to conventional methods. However, further validation through larger, interventional studies is necessary to standardize its use in clinical practice.

Evaluating the role of Mycobacterium tuberculosis PCR in ruling out active tuberculosis

Laboratory algorithms using Acid-Fast Bacilli staining and Mycobacterium tuberculosis (Mtb) polymerase chain reaction (PCR) are often used to remove isolation precautions. A retrospective case review of 52 patients with culture-confirmed pulmonary Mtb revealed 4 subjects with negative sputum Acid-Fast Bacilli smears and negative Mtb PCRs. All had significant risk factors for Mtb and had a positive interferon-gamma release assay. A negative PCR test result does not exclude an Mtb diagnosis.

Diagnostic Value of Combined-Diagnostic Methods of Brain Tuberculoma Tissue Specimens: A Case Series.

Background: The diagnosis of brain tuberculoma (BT) is sometimes challenging. Herein, we presented a case series to evaluate the combined-diagnostic methods, including acid-fast bacilli (AFB) stain, polymerase chain reaction (PCR), Gene Xpert, and histopathology, of tuberculoma tissue specimens (TTSs). Patients and Methods: A total of 16 patients (11 human immunodeficiency virus [HIV]-positive, 5 HIV-negative) with BT confirmed by combined-diagnostic methods of TTS were included in this study. Clinical data, including clinical symptoms, laboratory tests, neuroimaging features, histopathology, treatment, and prognosis, were assessed in all patients. Results: There were 10 male and 6 female patients (range, 18-73 years). Acid-fast bacilli stain and PCR of TTSs were positive in 11 and 10 patients, respectively. The sensitivity of Gene Xpert of TTSs was (80.0%; 8/10). Nine (56.3%; 9/16) patients were diagnosed with BT by histopathology. After receiving antituberculosis treatment, 12 (75.0%; 12/16) patients improved clinically to a considerable extent. Conclusions: The combined-diagnostic methods of TTS may improve the diagnostic efficiency of BT.

Rare Extrapulmonary Tuberculosis: Covert symptoms and Diagnostic Dilemma.

Pulmonary tuberculosis may result in haematogenous and lymphatic extension in case of failure of early detection, or immunocompromised status, leading to extrapulmonary tuberculosis. Rare sites of extrapulmonary tuberculosis include the gastrointestinal tract, musculoskeletal system, genital tract, middle ear and pericardium. Histopathological findings of macro-confluent granuloma with or without caseous necrosis, along with detection of acid-fast bacilli (AFB) on Ziehl-Neelsen (ZN) staining, and GeneXpert for detection of Mycobacterium tuberculosis DNA, are key in establishing a diagnosis of tuberculosis. Biopsy-proven extrapulmonary granulomatous lesions were included in this study. Histopathological evaluation of all extrapulmonary biopsy specimens sent to the Department of Pathology were done for the presence of granuloma and necrosis, and ZN staining for AFB was done in all the cases of granulomatous lesions with or without the presence of necrosis. The same cases, with biopsy specimens sent in normal saline, were re-evaluated in a molecular laboratory with the help of GeneXpert MTB to detect the DNA of Mycobacterium tuberculosis. All biopsy specimens from extrapulmonary sites which were sent to the Department of Pathology were used for DNA extraction. Out of the 10 cases of extrapulmonary granulomatous lesions, 8 showed caseous necrosis on microscopy, and 7 showed the presence of acid-fast bacilli on Ziehl-Neelsen staining. GeneXpert detected DNA of Mycobacterium tuberculosis in 9 cases. Extrapulmonary tuberculosis rarely occurs as primary, and mostly spreads from lung parenchyma via a haematogenous route. Tuberculosis of the gastrointestinal tract, peritoneum, lymph nodes, and solid viscera are together termed abdominal tuberculosis. Entities like tuberculosis of the pericardium and ear are extremely rare. Extrapulmonary tuberculosis should be a differential in cases of chronic non-responding cases with diagnostic dilemmas. To avoid diagnostic delay, in cases of high suspicion, one should go for biopsy along with ZN staining for diagnostic confirmation as this is cost-effective, followed by GeneXpert for Mycobacterium tuberculosis in highly suspected cases with absent caseous necrosis and negative ZN staining.

Granulomatous myocarditis arising from intravesical Bacillus Calmette–Guérin therapy leading to death diagnosed by postmortem examination: a case report

BackgroundIntravesical Bacillus Calmette–Guérin (BCG) is used as a standard adjuvant therapy for non-muscle invasive urothelial cancer. Most patients tolerate the treatment well, with mild side effects. Systemic complications are extremely rare, occur due to BCG dissemination and are associated with immunocompromised state and urothelial breach.Case presentationWe present a case of a 78-year-old male, a former smoker, with history of non-muscle invasive urothelial carcinoma status post partial resection followed by intravesical BCG therapy. An autopsy was performed due to the sudden nature of his death. Autopsy showed multiple necrotizing granulomas in the brain, atrium, ventricles, lungs, kidneys, and urinary bladder. Stains for acid-fast bacilli and fungi were negative. In addition, bilateral lungs showed evidence of bronchopneumonia secondary to cytomegalovirus.ConclusionGranulomatous myocarditis arising from BCG therapy is extremely rare. Our patient with urothelial cancer treated with BCG developed multiorgan granulomas, most likely due to a hypersensitivity reaction to intravesical BCG. Arrhythmia induced by granulomatous myocarditis was the cause of his death. Although there have been few cases of systemic BCG-osis causing fatal sepsis leading to death, a cardiac cause of death is unique.

Radiological changes in leprosy patients with disabilities and deformities of hands and feet

Background/Aim: Leprosy (Hansen's disease) affects the skin and nerves. Hands and feet are commonly involved in all types of leprosy often leading to deformities. This study explored radiological changes in leprosy patients with hand and foot disabilities/deformities. Methods: Observational retrospective study was the chosen design. Study was conducted on 50 leprosy patients presenting at a tertiary care hospital with hand and foot disabilities during 2020-2022. Leprosy types were clinically diagnosed, confirmed by acid-fast bacilli staining. Bacteriological index (BI) and morphological index (MI) were calculated via Ridley's scale. Histopathological examination of the skin lesions was also conducted. Radiological exams, anteroposterior and lateral X-rays, identified specific/non-specific bone changes. Results: Mean age was 38.8 years, bone changes identified at 40.3 years. Radiological changes were seen in 42.0 % patients (34 % patients had non-specific and 16 % had specific changes). These changes were seen more common and earlier in females as compared to males, the difference however was not significant (p = 0.6). Mean BI (2.8) and MI (32 %) of the patients with bone changes were slightly higher than those without bone changes but the differences were not statistically significant (2.2 and 27 %) (p = 0.2). Common specific changes were periostitis and subarticular erosion while osteopenia and phalangeal resorption were the most common non-specific changes. Conclusion: Non-specific bone changes were more common than specific ones and in females as compared to males. Lepromatous leprosy (LL) was associated with maximum bone changes with varied involvement in other types of leprosy.

Utility of a Clinical Scoring System (Bandim TB Score and Karnofsky Performance Score) to Assess Mycobacterial Burden in Terms of Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) Cycle Threshold Values Among Pulmonary TB Patients.

Tuberculosis (TB) continues to be a global public health problem. Physicians fail to clearly interpret cycle threshold (Ct)values as a measure of mycobacterial burden due to the paucity of literature correlating Ct values with the clinical scoring. This study aims to correlate the clinical scoring parameters (Bandim TB scoreand Karnofsky Performance score (KPS)) with Ct values obtained by Cartridge-Based Nucleic Acid Amplification Test (CBNAAT). The study spanned from November 2019 to October 2021, during which a total of 40 cases were recruited. These cases were identified as pulmonary TB patients based on Ziehl-Neelsen staining for acid-fast bacilli and/or the GeneXpert MTB/RIF assay. Bandim TB scores and KPSs were recorded using standardized questionnaires. There was a strong negative correlation between Bandim TB score and Ct value (mean), and this correlation was statistically significant (rho = -0.82, p < 0.001). There was a moderate positive correlation between KPS and Ct value (mean), and this correlation was statistically significant (rho = 0.57, p < 0.001). No literature has compared Bandim TB score and KPS with the Ct values obtained by CBNAAT for pulmonary TB. Thus, the knowledge on the proper utilization of CBNAAT cycle threshold values and its correlation with clinical scoring parameters will help clinicians in the early identification and prompt initiation of appropriate treatment.

Diagnostic value of bronchoscopy in sputum‑negative presumptive pulmonary tuberculosis patients and its clinicoradiological profile

Abstract: CONTEXT: Tuberculosis (TB) remains endemic in India. Little local data have been reported on bronchoscopic evaluation of sputum‑negative pulmonary TB patients, which poses a significant diagnostic and therapeutic challenge. AIMS: To determine the diagnostic value of bronchoscopy and bronchoalveolar lavage (BAL) and its clinical and radiological profile in sputum‑negative, pulmonary TB patients. METHODS: We performed an analysis of patients with probable pulmonary TB with overall negative (smear and/or polymerase chain reaction [PCR]) or scanty sputum that had undergone bronchoscopy with BAL over a period of 11 months. Patients’ symptoms, radiological features, lung lobe lavaged, BAL acid‑fast bacilli (AFB) stain, Mycobacterium TB (MTB)‑PCR, and mycobacterial cultures were analyzed. Mycobacterial culture was used as a reference standard. RESULTS: 54 patients underwent a diagnostic bronchoscopy. Dry cough and fever were the most common symptoms. Uncontrolled diabetes mellitus was the most frequent comorbidity identified in 15 (28%) patients. Fifty‑nine percent of the patients had diffuse lung infiltrates, with consolidation being the most common abnormality (41%), followed by cavitation (39%). Right upper lobe was the most frequent lung lobe lavaged (31%). BAL mycobacterial culture and MTB Polymerase Chain Reaction (PCR) were positive in 43 (80%) and 41 (76%) patients and BAL AFB was positive in 5 patients respectively. Using BAL culture as reference, male gender, predominant upper lobe disease, upper lobe lavage, and presence of cavities on chest imaging had the highest diagnosticyield (82%, 100%, 63%, and 89%, respectively) (P = 0.02,0.006, 0.03, and 0.02, respectively).There was 100% concordance among the three diagnostic modalities. CONCLUSIONS: An overall diagnostic yield of 80% was achieved with combined use of BAL MTB PCR, culture, and AFB staining. Keywords: Broncho alveolar lavage, bronchoscopy, Mycobacterium tuberculosis polymerase chain reaction, sputum negative, tuberculosis

Transbronchial brushing cytology and paired biopsy in endobronchial tuberculosis: A report of 72 cases focusing on the morphological features

Objectives: The objectives of this study were to review the transbronchial brushing cytology and histological specimens of endobronchial tuberculosis (EBTB) and to explore the morphological features, diagnostic pitfalls, and dilemmas. Material and Methods: Transbronchial brushing cytology and concurrent biopsy specimens obtained between July 2017 and June 2020 were reviewed. EBTB was confirmed based on the clinical response to the anti-TB treatment in addition to the positive findings of at least one of the following methods: Acid-fast bacilli stain (AFB), auramine-rhodamine stain (A-R), detection of TB bacterial DNA (TB-DNA) by polymerase chain reaction, T-cell spot test (T-spot), and typical pathologic changes of TB on cytology or bronchoscopy biopsy. A total of 72 confirmed cases were studied. Results: Of the 72 patients, 42/72 (58.3%) and 30/72 (41.7%) were female and male patients, respectively. Bronchoscopic findings revealed five subtypes of EBTB, including inflammation infiltration, ulceration necrosis, granulation hyperplasia, cicatrices stricture, and tracheobronchial malacia. AFB, A-R, TB-DNA, and T-spot were positive in 39, 26, 33, and 46 cases, respectively. The detection rate of necrosis in the cytological specimens (90.3%) was significantly higher than that in the biopsy specimens (77.8%; P &lt; 0.01). The percentage of Langhans giant cells detected by cytology (13.9%) was significantly lower than that detected by the pathological examinations of the tissues (38.9%) (P &lt; 0.01). The detection rates of metaplastic squamous cells and epithelioid cells showed no significant difference with respect to the cytology and biopsy findings. In addition to the two patients who had concurrent carcinomas, atypical cells were reported in nine patients through cytopathological diagnosis, among them two were suspected to have carcinomas, two were with the impression that spindle cell neoplasms could not be excluded, and the other five were considered as reactive atypia. Moreover, one biopsy could not rule out the well-differentiated squamous cell carcinoma. Conclusion: Some morphological variations may cause challenges in cytological evaluation. Moreover, diagnostic dilemmas can occur even in the assessments of tissue pathology.

Comparison of 2 PCR assays on environmental samples cultured for Mycobacterium avium subsp. paratuberculosis.

Mycobacterium avium subsp. paratuberculosis (MAP) is the causal agent of paratuberculosis, a chronic, contagious, and incurable enteric disease of ruminants. An in-house IS900 PCR assay validated for MAP detection in sheep has been shown to have a higher sensitivity than a commercial PCR and fecal culture. We have now compared the performance of this in-house IS900 PCR assay with a commercial ISMap02 PCR assay for the detection of MAP DNA in bovine dairy farm environmental samples. We purposefully selected 30 culture-positive, 62 culture-negative, and 62 non-interpretable environmental samples. We applied the IS900 PCR assay directly to the frozen inoculum of these samples. Inocula were incubated in an automated system, and growth was confirmed by an acid-fast bacilli stain and the IS900 PCR assay. Among culture-positive samples before incubation, the IS900 PCR assay yielded significantly more positive results than the ISMap02 PCR assay; however, among culture-negative samples, the IS900 PCR assay yielded positive results both before and after incubation. The ISMap02 PCR assay did not flag positively among the culture-negative samples either before or after incubation. The IS900 PCR assay is a sensitive method that can be used to detect MAP DNA in environmental samples before incubation. The ISMap02 PCR assay is a specific method used to detect MAP DNA in environmental samples both before and after incubation.

Value of ultrasound guided biopsy combined with Xpert Mycobacterium tuberculosis/resistance to rifampin assay in the diagnosis of chest wall tuberculosis.

The thoracic wall lesions, particularly chest wall tuberculosis, and chest wall tumors and other pyogenic wall and actinomycetes infections, almost always present as a diagnostic challenge. To explore the value of ultrasound-guided biopsy combined with the Xpert Mycobacterium tuberculosis/resistance to rifampin (MTB/RIF) assay to diagnose chest wall tuberculosis. We performed a retrospective study of patients with chest wall lesions from March 2018 to March 2021. All patients received the ultrasound-guided biopsy for pathology examination, acid-fast Bacillus staining, mycobacterial culture, and Xpert MTB/RIF analysis. The sensitivity, specificity, and area under the curve (AUC) were calculated for these diagnostic tests, either individually or combined. Rifampicin resistance results were compared between the mycobacterial culture and the Xpert MTB/RIF assay. In 31 patients with the chest wall lesion biopsy, 22 patients were diagnosed with chest wall tuberculosis. Of them, 3, 6, and 21 patients tested positive for mycobacterial culture, acid-fast stain, and Xpert MTB/RIF assay, respectively. The rifampicin resistance results of the 3 culture-positive patients were consistent with their Xpert MTB/RIF assay results. When considering the sensitivity, specificity, and AUC value, the Xpert MTB/RIF assay (95.5%, 88.9%, and 0.92, respectively) was a better choice than the acid-fast Bacillus stain (27.3%, 100.0%, and 0.64, respectively) and mycobacterial culture (13.6%, 100.0%, 0.57, respectively). No complications were reported during the procedure. Ultrasound guided biopsy combined with Xpert MTB/RIF has high value in the diagnosis of chest wall tuberculosis, and can also detect rifampicin resistance.

SAT612 Granulomatous Mastitis: An Unusual Presentation Of Prolactinoma

Abstract Disclosure: H.R. Alkaissi: None. E. Kim: None. S. McFarlane: None. Background: Granulomatous mastitis (GM) is a rare, benign inflammatory breast disease of unclear etiology with clinical presentation that is similar to inflammatory breast cancer and periductal lobular mastitis. It occurs mainly in younger females and during the postpartum period. Prolactin (PRL) is an essential hormone of pituitary and extrapituitary origin that promotes lactation and the development of mammary glands within breast tissues. In addition to its lactogenic effect, it has over 300 other effects, several of which are immunomodulatory, including the expression and secretion of proinflammatory cytokines from macrophages. Clinical Case: A 37-year-old African American woman presented with right breast pain and swelling for a few weeks. Her medical history includes amenorrhea for five years. She is gravida 1, para 1 with normal spontaneous vaginal delivery at the age of 20. Physical exam showed non-bloody, non-purulent nipple discharge bilaterally, otherwise unremarkable. A breast ultrasound showed a 1 cm complex cystic mass. Biopsy showed benign breast tissue, with noncaseating granulomas formed by macrophages (CD68 positive on immunohistochemistry). Ziehl-Neelsen staining for acid-fast bacilli was negative. Staining for fungi was also negative. Prolactin level was 237 ng/mL. TSH, IGF-1, and ACTH were within normal. Pituitary MRI showed a focus of abnormal signal and diminished enhancement measuring 2.8x3.2x4.2 mm within the left side of the pituitary gland is compatible with a microadenoma. The patient was started on bromocriptine 2.5mg daily. Discussion: Our patient represents a rare case of granulomatous mastitis in the setting of microprolactinoma, likely long-standing, given the five years history of amenorrhea. The immunomodulatory effect of PRL on several immune system cells, including B-cells, T-cells, and macrophages, might be an underlying mechanism. In a recent study of 25 samples of GM, metagenomics studies identified unusual organisms in 68% of the samples. Of these, Corynebacterium kroppenstedtii was the most common (60%), followed by Pseudomonas oleovorans (16%), Epstein-Barr virus (4%), Acinetobacter baumannii (4%), and Tepidiphilus thermophilus (4%). In addition, 50% of the patients had elevated PRL, and elevated immunological markers, such as C3 and IgA [1]. This suggests that GM results from an interaction between the presence of certain pathogens in a host with elevated PRL that mediates proinflammatory response.

Tuberculosis of the scalp in a 13-year-old child: A common entity at an uncommon location – A rare case report

ABSTRACT Tuberculosis (TB) caused by Mycobacterium tuberculosis manifests as pulmonary and extrapulmonary forms with cutaneous TB being rare and TB of scalp even rarer. We report the case of a 13-year-old girl who was admitted with a 4-week history of painful swelling and ulcer on the scalp and occasional cough. She had a history of falling on the head 6 months ago. On physical examination, the ulcer measured 6 cm in diameter and was tender with a yellowish-white crust. Contrast-enhanced computed tomography of the head showed a well-defined hypodense peripherally enhancing lesion overlying the left parietal bone with the destruction of the underlying bone. A clinical diagnosis of frontal bone osteomyelitis was made. Abscess drainage was done with excision of the lesion which on histopathological examination showed abundant necrosis with few ill defined epithelioid cell granulomas, langhans type of giant cells, and chronic inflammatory infiltrates. Ziehl–Neelsen staining for acid-fast bacilli was negative, whereas molecular testing by GeneXpert Rifampicin Assay was positive for M. tuberculosis. Thus, a diagnosis of tubercular osteomyelitis was made. Our patient was prescribed four drugs antitubercular regimen for 1 year. On follow-up after 6 months, she is doing fine without any signs and symptoms of the disease. TB should always be kept in mind as the differential diagnosis keeping its varied presentation and high prevalence in our country.

Drug Resistance in Osteoarticular Tuberculosis: A Study From an Endemic Zone.

The present study was undertaken to determine the incidence of drug resistance against anti-tubercular drugs among patients from an endemic zone. Methodology: Forty consecutive clinico-radiologically diagnosed patients of osteoarticular tuberculosis (29: spine, 11: extraspinal) were enrolled. Pus from needle aspiration was taken in 31 cases, tissue following spinal decompression in seven, synovial in one, and sinus edge biopsy in one. The pus/tissue was subjected to acid-fast bacilli (AFB) staining and liquid culture, sensitivity to 13 anti-tubercular drugs (Isoniazid (INH), rifampicin (RIF), kanamycin (KAN), amikacin (AMK,) capreomycin (CAP), ethionamide (ETH), levofloxacin (LEV), moxifloxacin (MOX), linezolid (LNZ), para-amino-salicylic acid (PAS), bedaquiline (BDQ), delamanid (DLM), and clofazimine (CFO)) were checked, and histopathological/cytopathological examination and molecular tests were performed. Results: The mean age of patients was 29.07(9-65) years; 21 were female and 19 were male. The diagnostic accuracy for tuberculosis was 20% by AFB smear, 65% by liquid culture, 82.5% by histopathology, and 90% by cartridge-based nucleic acid amplification testing (CBNAAT). All culture-positive isolates were identified as Mycobacterium tuberculosis with no non-tubercular Mycobacterium. The drug resistance detected on CBNAAT was 11.1%, line probe assay (LPA) first line was 15.4%, LPA second line was 4%, and liquid drug susceptibility testing (DST) 11.5%. We detected 15.4% INHresistance, 11.1% RIF, 7.6% LEV, 3.8% MOX and PAS. No resistance was detected against second-line injectable drugs (SLID), ETH, LNZ, BDQ, DLM, and CFO. Conclusions: No single laboratory modality can ascertain the diagnosis in all cases; hence, samples should be sent for all tests in tandem. In the presence of insufficient samples, tissue may be subjected to CBNAAT and histopathology to arrive at tissue diagnosis. In this subset, overall drug resistance incidence was 12.5% (5/40) with one patient each of isolated INH and RIF resistance, one of multidrug-resistance (MDR), and two of pre-extensively drug-resistant (pre-XDR). Primary drug resistance came out to be 11.1% (4/36) with one patient each of isolated INH and RIF resistance, one ofMDR, and one Pre-XDR.