Acid-fast Bacilli Staining Research Articles

Does Polymerase Chain Reaction of Tissue Specimens Aid in the Diagnosis of Tuberculosis?

BackgroundMycobacterial culture is the gold standard test for diagnosing tuberculosis (TB), but it is time-consuming. Polymerase chain reaction (PCR) is a highly sensitive and specific method that can reduce the time required for diagnosis. The diagnostic efficacy of PCR differs, so this study determined the actual sensitivity of TB-PCR in tissue specimens.MethodsWe retrospectively reviewed 574 cases. The results of the nested PCR of the IS6110 gene, mycobacterial culture, TB-specific antigen-induced interferon-γ release assay (IGRA), acid-fast bacilli (AFB) staining, and histological findings were evaluated.ResultsThe positivity rates were 17.6% for PCR, 3.3% for the AFB stain, 22.2% for mycobacterial culture, and 55.4% for IGRA. PCR had a low sensitivity (51.1%) and a high specificity (86.3%) based on the culture results of other studies. The sensitivity was higher (65.5%) in cases with necrotizing granuloma but showed the highest sensitivity (66.7%) in those with necrosis only. The concordance rate between the methods indicated that PCR was the best method compared to mycobacterial culture, and the concordance rate increased for the methods using positive result for PCR or histologic features.ConclusionsPCR of tissue specimens is a good alternative to detect tuberculosis, but it may not be as sensitive as previously suggested. Its reliability may also be influenced by some histological features. Our data showed a higher sensitivity when specimens contained necrosis, which indicated that only specimens with necrosis should be used for PCR to detect tuberculosis.

Evaluation of a PCR assay on overgrown environmental samples cultured for Mycobacterium avium subsp. paratuberculosis.

Culture of Mycobacterium avium subsp. paratuberculosis (MAP) is the definitive antemortem test method for paratuberculosis. Microbial overgrowth is a challenge for MAP culture, as it complicates, delays, and increases the cost of the process. Additionally, herd status determination is impeded when noninterpretable (NI) results are obtained. The performance of PCR is comparable to fecal culture, thus it may be a complementary detection tool to classify NI samples. Our study aimed to determine if MAP DNA can be identified by PCR performed on NI environmental samples and to evaluate the performance of PCR before and after the culture of these samples in liquid media. A total of 154 environmental samples (62 NI, 62 negative, and 30 positive) were analyzed by PCR before being incubated in an automated system. Growth was confirmed by acid-fast bacilli stain and then the same PCR method was again applied on incubated samples, regardless of culture and stain results. Change in MAP DNA after incubation was assessed by converting the PCR quantification cycle (Cq) values into fold change using the 2-ΔCq method (ΔCq = Cq after culture - Cq before culture). A total of 1.6% (standard error [SE] = 1.6) of the NI environmental samples had detectable MAP DNA. The PCR had a significantly better performance when applied after culture than before culture (p = 0.004). After culture, a 66-fold change (SE = 17.1) in MAP DNA was observed on average. Performing a PCR on NI samples improves MAP culturing. The PCR method used in our study is a reliable and consistent method to classify NI environmental samples.

Tonsillar tuberculosis : A case report

Tuberculosis of the oral cavity which is an uncommon occurrence can be primary or secondary. In the absence of active pulmonary tuberculosis, isolated tonsillar tuberculosis is rare. Herein, we report two cases of bilateral tonsillar tuberculosis who presented as recurrent sore throat for which tonsillectomy was done. No active primary pulmonary lesion was found in these cases. Histopathological examination revealed caseating epithelioid granulomas with Langhans giant cells. Ziehl Neelson stain for acid fast bacilli was positive in one case. Tonsillar tuberculosis, though a rare entity, should be considered in the clinical differential diagnosis of tonsillar lesions. Histopathological examination with Ziehl Neelson stain should be performed for definite diagnosis.

Retrospective analysis of seven breast tuberculosis cases.

The present study aimed to evaluate the demographic data, diagnostic methods, therapeutic regimens and duration of therapy in 7 breast tuberculosis (BTB) cases. The data of BTB cases treated between January 2006 and December 2013 were retrospectively evaluated, with a total of 648 tuberculosis (TB) cases recorded during the 8-year period. Among these cases, 296 patients (50%) suffered from pulmonary TB, 278 (43%) from non-pulmonary TB and 45 (7%) from PTB plus NPTB. In total, 7 BTB were diagnosed, which constituted 1.08% (7/648) of all TB cases and 2.51% (7/278) of all NPTB cases. The mean age of patients was 34±9.46 years, with no pregnant or lactating women. Bilateral breast involvement was detected in only 1 case, while all cases had a BCG scar, and obtained a mean tuberculin skin test (TST) result of 14.28±6.79 mm (range, 7-26 mm). The symptoms included presence of a mass, tenderness, pain, swelling and fluctuation in the breast, with or without discharging sinuses. In 1 case, history of contact with TB was found. All patients were newly-diagnosed BTB cases, with no other organ involvement. Upon histopathological examination of breast tissue, granulomatous inflammation with typical caseous necrosis was observed in 1 case, non-caseous necrosis inflammation was detected in 2 cases, granulomatous inflammation was observed in 3 cases, and mastitis and fat necrosis inflammation was observed in 1 case. Acid-fast bacilli (AFB) staining was positive in only 2 cases, and all patient were treated with anti-TB drugs with a successful outcome and no recurrence. In conclusion, BTB is a rare form of TB and the present retrospective study reported 7 cases of BTB along with the results of histopathological examination, microbiological examination and treatment. TB must be considered when there is presence of breast masses presenting with tenderness, pain, swelling and fluctuation, with or without discharging sinuses.

Impact and safety of endoscopic ultrasound guided fine needle aspiration on patients with cirrhosis and pyrexia of unknown origin in India.

Background and aims: Etiologic diagnosis of pyrexia of unknown origin is important in patients with cirrhosis for optimal management and to prevent flare up of infectious disease after liver transplantation. However, there is very limited literature available on this subject. The present study aimed to examine the safety and impact of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with cirrhosis. Methods: The study was conducted between January 2014 and January 2016 at a tertiary care center. A total of 50 (47 lymph nodes, 3 adrenal) EUS guided FNAs were performed in 46 patients. Data are presented as median (25 – 75 IQR). Results: The study included 46 patients (40 males) whose mean age was 47.9 ± 11.1 (SD) years; mean Child-Turcotte-Pugh (CTP) score and mean MELD (Model for End-Stage Liver Disease) score were 10 (8 – 11) and 18 (12 – 20), respectively. The Child Pugh class was A in 4, B in 14, and C in 28 (including three patients with adrenal FNAs). Indications for FNA were pyrexia of unknown origin and lymphadenopathy on CT imaging. The cytopathological diagnoses were metastatic disease in 1 (adrenal), granulomatous change in 10 (6 positive with acid fast bacilli stain), histoplasmosis in three (two adrenals, one lymph node), 32 lymph nodes were reactive and four lymph node FNAs showed inadequate cellularity. The pathologic nodes had significantly lower long-to-short axis ratio [1.25 (1.09 – 1.28) versus 1.46 (1.22 – 1.87), P = 0.020]; a higher proportion of hypoechoic echotexture (5 versus 3, P = 0.017), and sharply defined borders (4 versus 2, P = 0.029). Complications included mild hepatic encephalopathy related to sedation in two patients with Child’s C status. Conclusion: EUS guided FNA is safe in patients with cirrhosis and modified the management in 14/46 (30.4 %) patients.

Whole lung lavage for lipoid pneumonia

We evaluated a 49-year-old woman who had worsening shortness of breath, non-productive cough and recurrent low-grade fevers over 6 months despite several courses of antibiotics. Her medical history was remarkable...

Significance of IFN-ɤ/IL-2 Ratio as a Circulating Diagnostic Biomarker in Extrapulmonary Tuberculosis.

Extrapulmonary tuberculosis (EPTB) remains a challenging diagnosis both for clinicians and microbiologists. We hypothesized that the profile of IFN-ɤ/IL-2 ratio in clinically diagnosed cases of EPTB would be distinct from that of age- and sex-matched healthy controls. Therefore, in our study, we have assessed the ratio of serum levels of IFN-ɤ and IL-2 in clinically diagnosed cases of EPTB to assess their potential role as diagnostic biomarkers. Sixty-nine (69) clinically confirmed EPTB cases and 69 age- and sex-matched healthy controls were included in the study. All the extrapulmonary specimens were subjected to Ziehl-Neelsen staining for acid-fast bacilli and culture on Lowenstein-Jensen (LJ) medium. Detection of serum levels of IFN-ɤ and IL-2 was carried out using commercially available ELISA kits following manufacturers' instructions. The ratio of serum levels of IFN-ɤ and IFN-ɤ/IL-2 was discriminative for the diagnosis of EPTB cases (p<0.001), although the same was not observed with IL-2 (p>0.05). Distribution of all biomarkers significantly differed between culture-positive and culture-negative cases (p<0.05). Among the smear-positive and smear-negative ones, only IFN-ɤ and IFN-ɤ/IL-2 ratio could significantly differentiate (p<0.05). Ratio of IFN-ɤ and IL-2 rather than the individual levels was the best discriminatory biomarker with the highest area under the ROC curve. Although IFN-ɤ and IFN-ɤ/ IL-2 ratio could aid in the diagnosis of EPTB, IL-2 has a limited utility in the diagnosis of EPTB. Further elaborate studies to validate these results are required.

A Hospital Based Study on Female Genital Tuberculosis in Central India

Introduction: In developing countries like India tuberculosis (TB) is common and still a major cause of infertility. Female genital tuberculosis is one form of extra pulmonary TB. Genital TB may be asymptomatic and diagnosis requires a high index of suspicion. Early diagnosis may improve the outcome before permanent tissue damage get established. The objective of this study was to evaluate the prevelance and clinico-pathological aspects and diagnosis of female genital tuberculosis (FGTB). Method: A total of 21 cases of female genital tuberculosis were diagnosed from 1672 patients over a period of 2 years, studied from January 2013 to December 2015. The diagnostic procedure used were endometrial curettage and biopsy, histopathological examination, culture, stain for Acid fast bacilli in correlation with clinical presentation ,organ involvement, hysterosalpingography(HSG), Ultrasonography (USG)and laparoscopy. Most of the specimens received were endometrial curettage and biopsies. Result: Female genital TB accounted for 1.25% of all tuberculosis patients in this study. The highest incidence was between 21-30 years of ages, but the patient ranged from 18-60 years. FGTB involves the endometrium (16 ), fallopian tube (4),cervix (1). Out of all cases, 7 demonstrate typical epitheloid granuloma and rest with atypical tuberculous lesion, acid-fast bacilli in tissue section were detected in 3 cases of endometrium, 1 case of fallopian tube and culture positive in 3 cases of endometrium, 1 case of fallopian tube. Conclusion: Female genital tuberculosis is not uncommon in developing countries like India and indicates a strong relation between genital TB and infertility. The diagnosis of FGTB is challenging. Therefore, if possible genital TB is to be frequently diagnosed and considered in differential diagnosis of causes of infertility, in correlation with clinical and other diagnostic modalities.

57-Year-Old Man With Hip Pain and Lytic Bone Lesions

57-year-old man presented to his primary care physician with a 2-year history of progressive right hip pain. His medical history was notable for hyperlipidemia. He was up-to-date on sex- and agespecific cancer screening. The patient had no history of chest pain, palpitations, shortness of breath, cough, or other cardiac, respiratory, neurologic, or visual symptoms. He had no recent travel history or occupational or social contact with persons who were ill. Physical examination revealed an obese man (body mass index [calculated as weight in kilograms divided by height in meters squared], 40.34 kg/m 2 ) with normal vital signs and unremarkable findings on cardiac, respiratory, abdominal, neurologic, and lymphatic examination. No pain or tenderness was elicited on examination. He was treated initially with nonopioid pain medications. Sacroiliac corticosteroid injections were minimally beneficial. Results of a complete blood cell count (CBC) and electrolyte panel were normal with the exception of an elevated serum calcium level of 11.7 mg/dL (reference range, 8.9-10.1 mg/dL). Ultimately, magnetic resonance imaging (MRI) of his lumbar spine revealed numerous punched-out lytic lesions in the lumbar vertebra and pelvis. He underwent computed tomography (CT) of his chest, abdomen, and pelvis that identified further lytic lesions as well as multiple splenic lesions concerning for metastases. Two separate CT-guided bone biopsy samples of the lytic lesions in the lumbar vertebra did not elicit an etiology of the lesions.

FNAC of tubercular lymph node-An alternative to excision biopsy

Background: Tuberculosis is a major health problem in our country, India. Tuberculer involvement of cervical lymph node is very common. Diagnosis of tubercular lymphadenitis can be made by using various biochemical, micro bacteriological laboratory methods. Above all these methods stands Fine needle aspiration cytology (FNAC) of affected lymph node which is simple, quick, easy and effective method to diagnose tubercular lymphadenopathy. Aim: This study is done to 1. Study various cytological patterns of tubercular lymphadenitis & find out the AFB positivity of such cases. 2. To find out how far it can obviate the biopsy of tubercular lymph nodes for diagnosis. Material and Methods: Total 465 suspected cervical tubercular lymphadenopathy patients of were included in study. Detailed clinical history regarding duration of swelling, sites, size, consistency, and mobility were taken into account. Fine needle aspirations were done and the smears were air-dried and stained with May- Grunwald Giemsa (MGG) and Ziehl-Neelsen (ZN) stain for acid fast bacilli (AFB). Result: During this period of five years 465 patients of cervical lymphadenopathy were diagnosed as tubercular lymphadenitis. AFB positivity was 55.2%. Conclusion: FNAC can be used as diagnostic tool alone in case of tubercular lymphadenitis. Keywords: FNAC, Z-N staining, Tubercular

A Comparative Study of Induced Sputum and Bronchial Washings in Diagnosing Sputum Smear Negative Pulmonary Tuberculosis.

Tuberculosis is one of the most important public health problem worldwide. Detecting patients with active pulmonary Koch's disease is an important component of tuberculosis control programs. However, at times in patients even with a compatible clinical picture, sputum smears do not reveal acid-fast bacilli and smear-negative pulmonary tuberculosis remains a common problem. The present study is aimed to compare the results of induced sputum and bronchial washings smear in patients suspected to have sputum smear negative pulmonary tuberculosis. A prospective study conducted from August 2014 to July 2015, comprising 120 patients fulfilling study criteria. Patients with respiratory symptoms and chest roentgenogram suspicious of pulmonary tuberculosis with no previous history of anti-tuberculosis treatment and two spontaneous sputum smear samples negative for acid fast bacilli were included. Patients with active haemoptysis and sputum positive were excluded from the study. Sputum induction was done by using 5-10 ml of 3% hypertonic saline through ultrasonic nebulizer taking safety precautions. All the patient underwent fibreoptic bronchoscopy after six hours fasting on the same day. About 20 ml of normal saline instilled into the suspected pathology area and washings were taken with gentle suction. The sample processing and fluorescent staining for acid fast bacilli was done in a designated microscopy lab. Out of 120 sputum smear negative pulmonary tuberculosis patients, induced sputum smear examination detected acid fast bacilli in 76 patients (63.3%) and acid fast bacilli detected from bronchial washings in 94 patients (78.3%). Smear positivity was higher in cavitary and infiltrative lesions as compared to consolidation and infrahilar pattern disease. Even though both induced sputum and bronchial washings procedures were valuable for the diagnosis of sputum smear negative, sputum induction with hypertonic saline should be the initial procedure of choice, which can be repeated twice / thrice in a day or two consecutive days. If the patient still remains induced sputum smear negative and if the clinical probability of tuberculosis is high, starting anti-tuberculosis treatment and closely monitoring patient and reserving bronchoscopy to those patients who do not improve and to exclude alternative diagnosis seems to be a practically useful approach.

Tuberculomas Mimicking Posterior-Circulation Stroke

Dear Editor, Posterior-circulation stroke is of grave concern to any physician versed with the mortality and morbidity associated with the condition. Various nonvascular neurological and nonneurological conditions may mimic posterior-circulation stroke. We report a 29-year-old male with no prior comorbidities who presented to the emergency room of a tertiary-care hospital in northern India with sudden-onset alteration in consciousness following severe vertigo with multiple episodes of vomiting and gait imbalance. Detailed history-taking revealed the presence of pain in the nape of the neck and low-grade fever for the previous 10 days and a history of chiropractic neck manipulation for the previous 7 days. The possibility of acute posterior-circulation stroke following vertebral artery dissection was considered, and a computed tomography (CT) scan of the head was performed on an emergency basis. The CT scan revealed a large hypodensity in the midbrain, pons, and cerebellum (Fig. 1A). However, CT angiography of the neck and the intracranial vessels did not show any evidence of vertebral artery dissection. Routine hemogram, biochemistry, and chest X-ray findings were normal. The possibility of an alternative diagnosis was considered, based specifically on the history of preceding fever and the normal CT angiography findings. Magnetic resonance imaging (MRI) of the brain revealed multiple ring enhanced lesions in the cerebellum with significant surrounding perilesional edema (Fig. 1B and C). Cerebral spinal fluid (CSF) analysis showed a total count of 250 cells/mm3, predominantly lymphocytes, with proteins 90 at mg/dL and sugar at 35 mg/dL. Cryptococcal antigen, acid fast bacilli stain, and fungal smear findings were negative in the CSF. The blood sugar level was 121 mg/dL. The possibility of multiple infratentorial tuberculomas was considered, and the patient was started on antitubercular therapy with steroids. The patient was completely asymptomatic after 6 months of treatment. Fig. 1 A: Contrast enhanced CT head showing hypodensity of pons and cerebellum. B and C: Shows multiple ring enhancing lesions in cerebellum on contrast enhanced, T1 weighted MRI brain. Posterior-circulation stroke is associated with grave mortality and morbidity statistics.1 A population-based case-control study2 found that chiropractic manipulation was positively correlated with vertebrobasilar accidents, specifically in subjects aged <45 years. There are abundant data in the Western literature that have increased public concern about the safety of chiropractic manipulation, but the situation is different in developing countries. Various nonvascular neurological and nonneurological conditions may mimic posterior-circulation stroke, including acute peripheral vestibular dysfunction, acute intracranial hemorrhage, subarachnoid hemorrhage, basilar migraine, hypoglycemia, central pontine myelinosis, postinfectious disorders, tumors, and many toxic and metabolic disturbances.3 Although chronic infectious and inflammatory disorders may also simulate this condition, a hyperacute presentation should always be addressed immediately. Tuberculosis is a imitator. In 1961, Sievers4 termed tuberculosis as the second great imitator after syphilis, based on his observations in the Indian population of southwestern United States suffering from tuberculosis. Tuberculomas of the brain account for 20–30% of lesions occupying the intracranial space in India, and multiple such lesions are present in 15–30% cases.5 Tuberculomas can affect any part of brain, but those with an infratentorial origin are rare. There are isolated cases of brainstem or cerebellar tuberculomas reported in the literature. Though uncommon, infratentorial tuberculomas can be life-threatening.6 Gadolinium-enhanced MRI of the brain is a more sensitive modality for detecting tuberculomas. A retrospective analysis after performing brain MRI in the present patient produced consistent findings. While CT can be performed in most centers, it is not the diagnostic modality of choice, specifically when considering infratentorial lesions. Though clinically hyperacute presentations always warrant consideration of a vascular event, it must be remembered that tuberculosis is a great mimic, and can present with hyperacute presentations as described in the present case.

Spectrum of granulomatous lesions in a tertiary care hospital

Introduction: Granulomatous lesions comprise a large family of disorders sharing a common histological denominator of formation of granulomas, either immune or non-immune category with tuberculosis being the most common cause in our country. Aims and Objectives: To study the spectrum of granulomatous lesions in a tertiary care hospital, to categorise tuberculous versus non-tuberculous causes and to study the incidence of acid-fast bacilli (AFB) positivity in granulomatous lesions. Material and Methods: This is a retrospective descriptive study of all granulomatous lesions reported over a period of two years from November 2013 to November 2015. All cytology and histopathology cases reported as granulomatous inflammation during this period were taken for this study and, while granulomatous lesions of the skin (Hansens disease) were excluded. Histological findings and acid-fast bacilli staining were then analyzed. Result: In this study, majority of the patients were of 51-60 year age group (30%) followed by 41-50 years (21.42%). The majority of the patients were male (64.28%) followed by females (35.72%). Out of a total of 70 patients, 42.86% (30 cases) showed features of tuberculosis, out of which 7 were positive for Acid-fast bacilli by Ziehl Neelsen stain, and 22 were negative. Out of the 30 cases, 22 showed extensive caseation necrosis. One case of tuberculous lymphadenitis was associated with metastatic ductal carcinomatous deposits in axillary lymph node. 41.42 % showed chronic granulomatous inflammation, 4.29% showed foreign body granulomatous reaction (2 cases of fungal infection and 1 case of gossypiboma). 2.86% showed xanthogranuloma, 1.42% showed Lipogranuloma (chalazion). Conclusion: Tuberculosis is considered first in differential diagnosis of granulomatous diseases, especially in the countries with a high incidence of tuberculosis, but detailed analysis of clinical and ancillary studies are essential to rule out other granulomatous lesions. Exact diagnosi

Induced sputum versus bronchial washings in the diagnosis of sputum negative pulmonary tuberculosis.

Introduction:Tuberculosis (TB) is one of the most important public health problems worldwide. Detecting patients with active pulmonary TB (PT) is an important component of TB control programs. However, at times in patients even with a compatible clinical picture, sputum smears do not reveal acid-fast bacilli (AFB) and smear-negative PT remains a common problem. This study compares the results of induced sputum (IS) and bronchial washings (BWs) in detecting sputum negative PT.Materials and Methods:A prospective study conducted from June 2014 to June 2015, comprising 120 patients fulfilling study criteria. Patients with respiratory symptoms and chest roentgenogram suspicious of PT with no previous history of antiTB treatment (ATT) and two spontaneous sputum smear samples negative for AFB were included in the study. Patients with active hemoptysis and sputum positive were excluded from the study. Sputum induction was done using 5–10 ml of 3% hypertonic saline through ultrasonic nebulizer taking safety precautions. All the patients underwent fiberoptic bronchoscopy after 6 h fasting on the same day. About 20 ml of normal saline instilled into the suspected pathology area and washings were taken with gentle suction. The sample processing and fluorescent staining for AFB were done in a designated microscopy laboratory.Results:Of 120 smear-negative PT patients, IS smear examination detected AFB in 76 patients (63.3%) and AFB detected from BWs in 94 patients (78.5%). Smear positivity higher in cavitary and infiltrative lesions compared to consolidation and infrahilar pattern disease.Conclusions:Even though both IS and BWs procedures were valuable for the diagnosis of smear-negative TB, sputum induction with hypertonic saline should be the initial procedure of choice, which can be repeated twice/thrice in a day or 2 consecutive days. If the patient remains IS smear-negative and if the clinical probability of TB is high, starting ATT and closely monitoring patient and reserving bronchoscopy to those patients who do not improve and to exclude alternative diagnosis seems to be a practically useful approach.

Clinical and Pathological Evaluation of Mycobacterium marinum Group Skin Infections Associated With Fish Markets in New York City.

From December 2013 through May 2014, physicians, dermatopathologists, and public health authorities collaborated to characterize an outbreak of Mycobacterium marinum and other nontuberculous mycobacterial skin and soft tissue infections (SSTIs) associated with handling fish in New York City's Chinatown. Clinicopathologic and laboratory investigations were performed on a series of patients. Medical records were reviewed for 29 patients. Culture results were available for 27 patients and 24 biopsy specimens were evaluated by histopathology, immunohistochemistry (IHC) staining for acid-fast bacilli (AFB), and mycobacterial polymerase chain reaction (PCR) assays. All patients received antibiotics. The most commonly prescribed antibiotic regimen was clarithromycin and ethambutol. Of the 29 patients in this case series, 16 (55%) received surgical treatment involving incision and drainage, mass excision, and synovectomy. Of these, 7 (44%) had deep tissue involvement. All patients showed improvement. For those with culture results, 11 of 27 (41%) were positive for M. marinum; the remainder showed no growth. Poorly formed granulomas (96%), neutrophils (75%), and necrosis (79%) were found in 24 biopsies. Of 15 cases that were culture-negative and analyzed by other methods, 9 were PCR positive for M. marinum group species, 8 were IHC positive, and 3 were positive by AFB stains. A multidisciplinary approach was used to identify cases in an outbreak of M. marinum infections. The use of histopathology, culture, and IHC plus PCR from full thickness skin biopsy can lead to improved diagnosis of M. marinum SSTIs compared to relying solely on mycobacterial culture, the current gold standard.

Hepatic Tuberculosis: A Rare Cause of a Liver Mass in an Immunocompetent Host

Hepatic tuberculosis (TB) is an uncommon clinical entity seen in immunocompetent hosts and its diagnosis may be challenging. Hepatic TB may present in three main forms: diffuse hepatic involvement associated with miliary or pulmonary TB, granulomatous hepatitis, or tuberculoma/abscess that may mimic malignancy. Clinicians must maintain a high index of suspicion in order to avoid missing or delaying this diagnosis. A 24-year-old woman from the Philippines presented for evaluation of right upper quadrant (RUQ) pain and 20 lb weight loss. Five years prior to presentation, an abdominal MRI done for RUQ pain revealed a heterogeneous right liver lobe with mixed attenuation partially cystic focal lesions, punctate calcifications and peripheral biliary ductal dilatation concerning for neoplasm. She was subsequently lost to follow up. Upon re-presentation, her exam was notable for RUQ tenderness to palpation. Labs revealed total bilirubin 1.1 mg/dL, AST 169 U/L, ALT 280 U/L, and alkaline phosphatase 496 U/L. Serologic evaluation for underlying liver disease, HIV and infectious agents were negative except TB quantiferon was positive. Chest CT demonstrated scattered bilateral pulmonary nodules and a prominent right hilar lymph node. Abdominal CT revealed a complex mass in the right hepatic lobe with associated biliary ductal dilatation and calcifications concerning for metastatic malignancy. Sputum acid fast bacilli (AFB) stain and culture were negative. Fine needle aspiration of the liver mass revealed extensive granulomatous inflammation. Stains and cultures for fungi and AFB were negative. Core biopsy of the liver mass was performed, again yielding negative AFB stains and culture. Ultimately, TB PCR from the core samples returned positive. She was initiated on rifampin, isoniazid, pyrazinamide and ethambutol with continued follow up in TB clinic. This case highlights the diagnostic challenges associated with hepatic TB. While AFB stain and culture should be performed to evaluate for this entity, these are highly insensitive tests with culture yielding organisms in less than 10% of cases. TB PCR has demonstrated sensitivity of 53% with specificity of 96%, resulting in 90% positive and 76% negative predictive value. While PCR is not an ideal test, it's improved sensitivity over culture makes it extremely valuable in making the diagnosis of hepatic TB.Figure 1

Granulomatous Hepatitis as a Consequence of Disseminated Mycobacterium bovis (M. bovis)

A 77 year-old male with history of transitional bladder cell carcinoma diagnosed 12 years ago, presented for further evaluation of recurrent fever, night sweats and weight loss of 1-month duration. Previously he was treated with 3 transurethral tumor resections (TUR) over 7 years and 18 intravesicular Bacillus Calmette-Guerin (BCG) doses. His cancer recurred recently and he underwent a TUR 2 months prior to presentation followed by 2 intravesicular BCG doses, last dose 1 day prior to fever. An extensive infectious work up in the form of blood, urine, and radiographic evaluation was obtained and was negative. Blood and urine cultures were negative. He was empirically treated for BCG cystitis with an antimycobacterial (anti-TB) regimen consisting of isoniazid (INH), rifampin (R), ethambutol and vitamin B6 (B6). His fevers resolved on this regimen and he was discharged on this regimen. He was readmitted 10 days later with fevers. Repeat blood and urine cultures had no growth. In addition, he had mildly elevated transaminases, which were attributed to the R and was substituted with ciprofloxacin. With persistently elevated transaminases, a liver biopsy was done showing granulomatous hepatitis with non-necrotizing granulomas and negative acid-fast bacilli (AFB) stain. Due to BCG therapy, this histologic finding is most consistent with BCG-associated granulomatous hepatitis confirming the diagnosis of disseminated BCG. He was restarted on anti-TB therapy with INH, levofloxacin and B6. His fevers improved 5 days after initiation of therapy. He was discharged on these medications for a 6-month course. Surprisingly, 6 weeks later, initial blood and urine cultures grew M bovis. BCG is a live attenuated strain of M bovis. Intravesicular administration of BCG is commonly used as an adjuvant therapy in superficial bladder cancer. Disseminated BCG is a very rare complication following intravesicular BCG therapy. The prevalence of granulomatous hepatitis in disseminated BCG is 0.7%. Of patients with BCG-associated granulomatous hepatitis, only 10% of patients have tissue that test positive for AFB stains showing mycobacterial organisms. The mechanism by which BCG therapy can cause disseminated M bovis is not clearly understood. One thought is a Th1-mediated hypersensitivity reaction since a number of case reports demonstrated disseminated granulomas with negative AFB and no isolated organism. Our patient did have evidence of disseminated granulomas with negative AFB, but the organism was later isolated in his urine and blood, hence raising the hypothesis that the organism itself also can access the blood stream via uroepithelial cells and disseminate to other organs. In these cases, multi drug anti-TB therapy is recommended for three to six months with or without the addition of glucocorticoids.

Etiological diagnosis of granulomatous tubulointerstitial nephritis in the tropics.

BackgroundGranulomatous tubulointerstitial nephritis (GIN) is common due to infections, drugs or sarcoidosis. However, the cause is often difficult to establish and the studies are limited. We studied the etiology of GIN and compared the clinical and histological features and outcome in different etiologies at a tertiary care center in North India.MethodsRenaö biopsies from GIN cases diagnosed from January 2004 to April 2014 were retrieved. Stain for acid fast bacilli was performed in all biopsies. Etiological diagnosis was based on clinical features, extra-renal manifestations, radiology, history of drug intake and demonstration of infective agent. Tissue PCR for tubercular DNA was performed in seven biopsies.ResultsSeventeen GIN patients [mean age 35 ± 15 years; males 11] were identified. Tuberculosis was the commonest etiology followed by idiopathic, sarcoidosis and fungal. Both tuberculosis and sarcoidosis patients presented with subnephrotic proteinuria and raised serum creatinine. Acid fast bacilli were demonstrated in 1/9 and necrosis was demonstrated in 3/9 granulomas in tuberculosis. Tissue PCR for tubercular DNA was positive in six TB patients and negative in one sarcoidosis patient. Patients responded well to appropriate therapy.ConclusionEtiological diagnosis of GIN is essential for timely and appropriate therapy. Tuberculosis is the commonest etiology (53%) in the tropics. Necrosis in granuloma, demonstration of acid fast bacilli, blood interferon gamma release assay and urine culture is not sensitive for the diagnosis of tuberculosis in GIN. Our findings suggest that tissue PCR for tuberculosis performed in an appropriate clinical setting is useful in the diagnostic evaluation of GIN.

Have we made any headway in the diagnosis of neurotuberculosis? Place of real time PCR or real time PCR

The diagnosis of Central Nervous System tuberculosis (CNS TB) had been always an enigma as yield of Mycobacterium tuberculosis in cerebrospinal fluid (CSF) is very low and diagnosis mainly rested on combination of clinical, CSF analysis and radiological findings. We attempted to find whether 16s rRNA primer based real time Polymerase chain reaction (PCR) aids in diagnosis of tubercular meningitis (TBM) and tuberculoma. Literature is flooded with newer techniques for the diagnosis of neuro-tuberculosis by real time PCR. But no clear cut guidelines are available about their role. 40 cases of tubercular meningitis, diagnosed on basis of Modified Ahuja Criteria and 40 controls were included in this prospective study. All patients were evaluated clinically and investigated in detail including cerebrospinal fluid analysis, Acid Fast Bacilli staining, culture for TB by Bac T Alert 3-D system,16s rRNA real time PCR assay, chest X ray, computed tomography scans of head, contact survey using chest X-ray, Mantoux test and hemogram. Comparative analysis of real time PCR were done in control group vs. cases of TBM diagnosed on the basis of Modified Ahuja criteria. Results: CSF for tuberculosis by real time PCR was positive in 26/40 cases (65%) of TBM, as against 2/40 controls. Keeping the CSF culture as the gold standard its sensitivity is 62.50 (95% confidence intervals- 54.7, 85.2), specificity is 77.40 (95% confidence intervals- 54.7, 85.2), positive predictive value is 46.15 and negative predictive value is 88.89. Modified Ahuja criteria can serve as useful tool in diagnosis. CSF analysis by real time PCR has shown better sensitivity and quicker results than culture. However, it cannot be recommended alone as it was negative in about a third of cases. But its significance is underlined in early diagnosis and as an adjunct to culture.

Mycobacterium Strain and Type of Resistance in Pulmonary Tuberculosis Patients: A Missed Link in Iran’s National Tuberculosis Plan

Background:: The Incidence of multi-drug resistant tuberculosis (MDR-TB) is constantly increasing. Objectives:: This study aimed to clarify an important missed link in Iran’s national TB plan. Patients and Methods:: Through a 9-month period, all pulmonary TB patients diagnosed based on the national TB protocol, in Shiraz TB center, were selected and culture of TB colonies, drug susceptibility testing (DST), polymerase chain reaction (PCR) for detection of IS6110 gene, Isoniazid (INH) and Rifampin (RIF) tuberculosis resistance were done to collect data. Data were analyzed using SPSS. Results:: In 92 included patients, (mean age 45.4 ± 15 years), DST results showed that 16 cases (17.4%) were resistant to INH, 19 (20.7 %) to RIF and 24 (26.1%) to both INH and RIF. Polymerase chain reaction identified IS6110 gene in 71 cases (77.2%) and gene mutations in 3 (3.2%) KatG, 3 (3. 2%) InhA, 9 (9.7%) both KatG and InhA, 17 (18.4%) rpoB and 20 (21.7%) in KatG, InhA and rpoB genes. Patients with INH-resistant tuberculosis were more than those with RIF-resistant (OR = 7.1). Conclusions:: Findings of the present study show that 4 out of five new cases of pulmonary TB patients who were diagnosed based on the national TB protocol (clinical symptoms and acid fast bacilli staining) had IS6110 gene (MTB, Mycobactrium TB) and at least one-fifth of this group had A kind of Drug Resistant TB. Therefore, by using PCR ,as a complementary test, it could be possible to start 1st line anti-TB drugs for only MTB cases (up to 77% of the patients) and 2nd line drugs for MDR cases (15% of cases). This policy aims to achieve safety and better outcome for patients while saving human and financial resources in health care system.