Acid-fast Bacilli Staining Research Articles

An Uncommon Cause of a Small Bowel Obstruction

Introduction: Sarcoidosis is a systemic granulomatous disease of unknown etiology, characterized by the formation of non-caseating granulomas. GI involvement is very rare and can occur in a patient with known sarcoidosis or as the initial manifestation of the disease. Small bowel obstruction secondary to sarcoidosis has been described in few case reports. Case Report: A 67 y/o female with previous history of inactive pulmonary sarcoidosis presented with five-day history of nausea, vomiting, abdominal pain, and constipation. Abdominal X ray and CT scan with contrast demonstrated a high grade small bowel obstruction. She was treated conservatively, but as her symptoms progressively worsened, diagnostic laparoscopy was performed and revealed skin tag appearing lesions on the antimesenteric surface of the mid jejunum causing inflammatory adhesions to the mesentery. The bowel was completely viable with no additional lesions in the liver, stomach or visible parts of the colon. Histopathology of tissue biopsy revealed lymphohistiocytic non-caseating granulomatous inflammation with multinucleated giant cells, consistent with sarcoidosis. The patient was discharged on prednisone taper dose with close follow up. Discussion: GI system involvement that is clinically recognizable occurs in 0.1-0.9% of patients with sarcoidosis, with one study revealed small intestine involvement in 0.03% of the cases. It usually occurs in patients in their fifth or sixth decade of life with evidence of multisystem sarcoidosis in approximately one-half of patients. Establishing a definitive diagnosis of GI sarcoidosis depends on three components: 1) Biopsy evidence of non-caseating granulomas in the “symptomatic organ”, 2) Exclusion of other causes of granulomatous disease, particularly mycobacterial, fungal, and parasitic infections, and 3) Clinical, radiographic, and optimally histopathologic evidence of sarcoidosis in at least one other organ system. Treatment of GI sarcoidosis depends on symptomatology. Asymptomatic patients can be monitored without active therapy, while symptomatic patients with organ involvement should be treated with steroid until a response to therapy is noted followed by gradual taper. The optimal duration of steroid treatment for GI sarcoidosis is not known, but experts recommend treating the initial manifestation for at least one year. Other treatments such as surgical intervention may be necessary in patients with bowel obstruction, perforation, or hemorrhage.Figure: Computed tomography (CT) scan of the abdomen demonstrated early complete bowel obstruction at the level of mid-jejunum (A,B). Gastrografin small bowel follow-through demonstrated failure of contrast to pass into the colon (C).Figure: Intraoperative demonstration of the skin tag appearing lesion at the level of mid jejunum causing inflammatory adhesions.Figure: Histopathology of the resected small bowel lesion (A) H&E stain revealed lymphohistiocytic non-caseating granuloma with multinucleated giant cells (black arrow). (B) Negative for acid fast bacilli (AFB) stain. (C) GMS stain negative for fungal infection.

Diagnostic Performance of Polymerase Chain Reaction Targeting Insertion Sequence (IS6110) for the Detection of Extra Pulmonary Tuberculosis

Background: The diagnostic challenges in extra-pulmonary tuberculosis remain to be addressed even though remarkable progress has been made in the diagnostics of pulmonary tuberculosis during the last decade. Methods: This study was conducted to evaluate the use of polymerase chain reaction (PCR) in diagnosis of definitive extra pulmonary tuberculosis patients, and to assess the performance of insertion sequence (IS)6110 based PCR assay as compared to conventional liquid culture by Microbial growth Indicator Tube (MGIT) 960 system. Results: A total of 792 clinical specimens were collected from clinically suspected extra pulmonary tuberculosis patients. The specimens included 22 ascitic fluids, 69 pleural fluids, 240 Cerebrospinal fluids (CSF), 386 endometrial tissues, 47 lymph nodes, 22 pus, one synovial fluid, one fallopian tube, two brain abscess and two ovarian cyst samples. All these clinical samples were subjected to Auromine O staining (FM) for acid fast bacilli (AFB) and culture on MGIT 960 tubes containing Modified Middlebrooks 7H9 broth medium. PCR was performed by targeting 123bp fragment of insertion sequence IS6110 of Mycobacterium tuberculosis. Our study of 792 specimens, revealed their 87.5% sensitivity to endometrial samples, 92.31% sensitivity for cerebrospinal fluid, and 66.66% sensitivity in Pleural fluid and 60% sensitivity in Lymph node samples. The combined sensitivity and specificity of the PCR IS6110 was calculated to be 85.71% and 82.91%, respectively. Conclusion: PCR using IS6110 primer was able to pick up more positivity in extra pulmonary samples as compared to conventional culture method for the detection of M. tuberculosis.

46-Year-Old Man With Lower Back Pain

46-Year-Old Man With Lower Back Pain

Confirmation of positive acid fast bacilli samples by tuberculosis bacilli culture

This study attempts to estimate the efficiency of acid fast bacilli(AFB) stain technique to diagnosis tuberculosis in the different samples. This study was performed in general Al-Diawynia hospital and Department of Microbiology, Medicine College, Al-Qadisiha University between October 2005 to October 2008. A total of 1654 clinical samples from 750 patients analyzed for acid-fast staining. These were 605 sputum, 67 bronchial wash, 42 pleural fluids, 4 urine, 7 ascetic fluids and 3 cerebrospinal fluids. The stained smear-positive were (5.3 %) distributed in different samples .Seventy five patients (10%) were evaluated by Lowenstein-Jensen (LJ) medium culture that it was employed as gold standard for tuberculosis diagnosis, of these 58 were culture-positive specimens. The sensitivity of Ziehl-Neelsen (ZN) stain Methods and LJ culture were (68.9 %) and (95.2 %) respectively. The specificity of ZN stain Methods and LJ culture were (88.2 %) and (45.4 %) respectively. The diagnosis accuracy of ZN stain Methods and LJ culture were (73.3 %) and (73.3 %) respectively. The positive predictive value of ZN stain Methods and LJ culture were (95.2 %) and (68.9 %), while negative predictive value were (45.4 %) and (88.2 %) respectively.

Direct detection of rpoB and katG gene mutations of Mycobacterium tuberculosis in clinical samples

ObjectivesTo study the rpoB and katG gene mutation rate and its markers. MethodsCross-sectional study methods were used to study Tuberculosis. A total of 45 sputum samples were collected from Annapurna Neurological Institute and Allied sciences. Then, acid fast bacilli staining were performed. Positive and negative samples were carried for conventional polymerase chain reaction identification and electrophoresis. ResultsOut of 45 samples, 3 were acid fast bacilli positive and the rest were negative. Male participants were more as compare to female participants and the mutation in rpoB and katG gene was found similar i.e. 6.66% among the total samples. ConclusionsWe can conclude that genetic mutation in Mycobacterium tuberculosis can be identified directly from the clinical samples. However, we have carried this study in less sample size and to validate research on large number of sample is recommended.

An Unusual Triad of Hemophagocytic Syndrome, Lymphoma and Tuberculosis in a Non-HIV Patient

Patient: Female, 58Final Diagnosis: Hemophagocytic syndrome • lymphoma and tuberculosis in a non-HIV patientSymptoms: Dizziness • feverMedication: —Clinical Procedure: —Specialty: Critical Care MedicineObjective:Rare co-existance of disease or pathologBackground:Lymphoma complicated with hemophagocytic syndrome and tuberculosis has been rarely reported. The clinical and radiological presentation of these potentially fatal conditions can be easily confused and there is a potential for misdiagnosis.Case Report:We present a 58-year-old Hispanic female who was admitted to the hospital with dizziness and fever. Her initial admission diagnosis was severe sepsis secondary to community acquired pneumonia. She was started on intravenous antibiotics. Due to mediastinal lymphadenopathy, lymphoma was considered as a differential diagnosis for which she underwent bronchoscopy and endobronchial ultrasound-guided sampling of her mediastinal lymph nodes. Lymph node aspirate was suggestive of lymphoma. Initial cultures were negative. Her clinical course was complicated with respiratory failure, cytopenia, and rapidly progressive cervical lymphadenopathy. The patient underwent cervical lymph node excision and bone marrow biopsy. The pathology of the lymph nodes confirmed T cell lymphoma, and bone marrow revealed hemophagocytosis. The patient was started on chemotherapy but she continued to deteriorate and died on day 20 of her hospital admission. Post-mortem results of cultures from a cervical lymph node biopsy and PCR were positive for Mycobacterium tuberculosis.Conclusions:We suggest an aggressive tissue diagnosis with staining for acid-fast bacilli for early diagnosis in patients presenting with hemophagocytic syndrome secondary to lymphoma as coexisting tuberculosis is a consideration. Tuberculosis re-activation should be considered in patients from an endemic region who present with lymphoma and a deteriorating clinical condition.

Tubercular mastitis: An institutional experience from a tertiary care centre of northern India

Background: Tuberculous mastitis (TM) is a rare extra pulmonary presentation of tuberculosis. It may be problematic to distinguish from carcinoma breast, a condition with which it may coexist. Fine needle aspiration cytology (FNAC) / biopsy are indispensable for diagnosis and tuberculosis culture when positive may be very valuable to guide antimicrobial therapy.Aims and Objectives: To disseminate the message to the concerned expertise that it can present a diagnostic problem on radiological and microbiological investigations, and thus a high index of suspicion is needed.Materials and Methods: 19 cases of tubercular mastitis between January 2012 to March 2014 were identified and included in the present study. Cytology and biopsy alongwith AFB stain was done for confirmation.Results: Age ranged between 23- 55 years (median 33 years). Axillary nodes were palpable in 9 (47.3%) patients. Acid Fast Bacilli stain which was positive in only 3 patients. All the 19 patients were started on antitubercular treatment.Conclusion: This study highlights the importance of early diagnosis and aggressive medical and if required surgical management to cure this disease.Asian Journal of Medical Sciences Vol.8(3) 2017 72-75

Symptomatic pancreatic sarcoidosis

Objective: Report the case of female patient with symptomatic pancreatic sarcoidosis. Methods: Case Report. Results: A 65-year-old female was referred for the evaluation of severe fatigability, poor appetite, weight loss over the past two months and abdominal pain. She denied smoking cigarettes or alcohol intake. A review of systems was unremarkable. Her physical exam revealed the abdomen was soft, non-distended and non-tender with normal liver and spleen span. She presented with leukopenia, hypercalcemia, elevated liver enzyme an elevated alkaline phosphatase and an elevated erythrocyte sedimentation rate. An abdominal CT scan demonstrated a pancreatic head mass with retroperitoneal lymph node enlargement Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) were not performed. A CT scan guided pancreatic mass biopsy was performed with uncertain results. Laparoscopic pancreatic biopsy demonstrated noncaseating granulomas with Langerhan giant cells and fibrosis. Both an acid fast bacilli stain and gram stain for a fungal infection were negative. The patient presented elevated Angiotensin converting enzyme levels. Oral prednisone 40 mg daily for 7 days followed by a 7 week tapering schedule was initiated. The patient's signs and symptoms improved abdominal CT scan 6 weeks after treatment revealed no change in the size of the pancreas and peripancreatic lymph nodes. After 8 week of prednisone she remains clinically stable without any abnormal laboratory parameters. Conclusion: Sarcoidosis is a chronic multiorgan disease that uncommonly involves the pancreas. Pancreatic involvement is usually asymptomatic and discovered on autopsy. However, doctors should be cognizant that sarcoidosis can present with symptomatic pancreatic mass, albeit rarely.

The application of IS6110-baced loop-mediated isothermal amplification (LAMP) in the early diagnosis of tuberculous meningitis.

Here, we evaluated the potential activity of rapid Mycobacterium tuberculosis detection with loop-mediated isothermal amplification (LAMP), for the early diagnosis of tuberculous meningitis (TBM). Patients with suspected TBM from January 2014 to December 2015 were reviewed retrospectively. The cerebrospinalfluid(CSF) was collected. Acid-fast bacillus (AFB) staining, MGIT 960 culture, real-time fluorescent quantitative polymerase chain reaction (RTFQ PCR) and LAMP were performed. A total of 200 patients were included in the study. Of which, 172 of them were diagnosed with TBM (86.00%). The sensitivities of AFB staining, MGIT 960 culture, LAMP and RTFQ PCR for TBM diagnosis were 2.91% (5/172), 12.79% (22/172), 43.02% (74/172), and 34.30% (59/172), respectively. The sensitivity of LAMP for TBM was significantly higher than those of AFB staining and MGIT960 culture (χ2 = 75.11, P < 0.001; χ2 = 43.88, P = 0.002). LAMP's sensitivity was however comparable to RTFQ PCR assay (χ2 = 2.08, P = 0.130). The specificity, positive predictive value and negative predictive value of LAMP in the diagnosis of TBM were 92.86% (26/28), 97.37% (74/76) and 20.97 % (26/124), respectively. The overall consistency between LAMP and RTFQ PCR in the diagnosis of TBM was 88.5% (177/200), with Kappa value of 0.870. The consistency between LAMP and MGIT960 culture was 71% (142/200), with Kappa value of 0.730. Among all the methods, LAMP had high sensitivity, specificity and positive predictive value, showing high consistency with MGIT960 culture and RTFQ PCR.

Primary tuberculosis of thyroid: a rare case report

Case report: The thyroid gland is rarely affected by tuberculosis. Incidence of tuberculosis of the thyroid is 0.1–0.4%. We present a case of a 43-year-old male with painless swelling over the front of neck with history of loss of weight. On local examination swelling was soft to firm, measuring 2×2 cm and moved with deglutition. Clinical diagnosis of colloid goitre was made. The patient’s complete blood picture, thyroid function test, and chest X-ray were normal. USG showed a hypoechoic lesion in the left lobe of the thyroid. On FNAC, 1 mL pus-like material yielded, which on microscopy showed caseous necrosis, with epithelioid cells, lymphocytes, histiocytes, plasma cells and occasional thyroid follicular cells. ZN stain for acid fast bacilli was positive. A diagnosis of granulomatous thyroiditis of Koch’s aetiology was made. Primary tuberculosis of thyroid was first diagnosed by Bruns in 1893, in a middle-aged woman with enlarged gland with no evidence of primary pulmonary tuberculosis. The reasons for reactive immunity of the thyroid for tuberculosis may be explained as bactericidal attribute of colloid in gland, extensive vascularity, high iodine content, and intact capsule of thyroid. Thyroid tuberculosis should always be considered as a differential diagnosis during assessment of a midline cervical mass, as preoperative diagnosis can avoid unnecessary surgery.

Investigation of tuberculosis prevalence by acid-fast stain, culture and real-time PCR method in forensic autopsies

Tuberculosis (TB) is still one of the most important diseases and causes of death in the world. We aimed to investigate TB prevalence in forensic autopsy cases in Turkey by the acid-fast bacilli (AFB) staining, TB culture and real-time polymerase chain reaction (RT-PCR) methods in paraffin-embedded tissues. From January 2012 to January 2015, 1676 tissue samples were examined under AFB staining and TB culture, and 85 paraffin-embedded tissue samples under RT-PCR from 14,083 prospectively-investigated forensic autopsy cases in the Istanbul Council of Forensic Medicine. Positivity with microbiological methods (AFB staining and/or TB culture and/or RT-PCR) was detected in 43 (0.3%) out of 73 (0.5%) cases in which TB was diagnosed with histopathological findings. Acid-fast bacilli were detected in 14 tissue samples by AFB staining, and a total of 11 tissue samples were found culture-positive in the Löwenstein-Jensen medium. Mycobacterium tuberculosis DNA was positive in 36 samples with RT-PCR. Eleven (15%) cases were detected as miliary tuberculosis. Microbiological sampling should accompany autopsy findings and histopathological sampling for post-mortem identification and notification of active TB during forensic autopsies. Diagnosis of TB in forensic autopsies would contribute to clarifying the cause of death and to the collection of epidemiological data in Turkey, particularly in ante-mortem undiagnosed cases.

Evaluation of Xpert MTB/RIF assay performance in the diagnosis of abdominal tuberculosis.

Background/AimsThe use of genetic probes for the diagnosis of pulmonary tuberculosis (TB) has been well described. However, the role of these assays in the diagnosis of intestinal tuberculosis is unclear. We therefore assessed the diagnostic utility of the Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay, and estimated the prevalence of multidrug-resistant (MDR) TB in the Indian population.MethodsOf 99 patients recruited, 37 had intestinal TB; two control groups comprised 43 with Crohn's disease (CD) and 19 with irritable bowel syndrome. Colonoscopy was performed before starting any therapy; mucosal biopsies were subjected to histopathology, acid-fast bacilli staining, Lowenstein-Jensen culture, and nucleic acid amplification testing using the Xpert MTB/RIF assay. Patients were followed up for 6 months to confirm the diagnosis and response to therapy. A composite reference standard was used for diagnosis of TB and assessment of the diagnostic utility of the Xpert MTB/RIF assay.ResultsOf 37 intestinal TB patients, the Xpert MTB/RIF assay was positive in three of 37 (8.1%), but none had MDR-TB. The sensitivity, specificity, positive predictive value, and negative predictive value of the Xpert MTB/RIF assay was 8.1%, 100%, 100%, and, 64.2%, respectively.ConclusionsThe Xpert MTB/RIF assay has low sensitivity but high specificity for intestinal TB, and may be helpful in endemic tuberculosis areas, when clinicians are faced with difficulty differentiating TB and CD. Based on the Xpert MTB/RIF assay, the prevalence of intestinal MDR-TB is low in the Indian population.

The Diagnostic Value of Urine Lipoarabinomannan (LAM) Antigen in Childhood Tuberculosis.

Diagnosis of Tuberculosis (TB) in children is difficult because the clinical presentation is not specific, the chest X-ray interpretation has low accuracy and sputum sample is difficult to obtain. Antigen detection test such as rapid urine LAM is a non-invasive alternative for diagnosing TB . Lipoarabinomannan (LAM) is the main component of M.tuberculosis cell wall. To determine the diagnostic value of urinary LAM antigen for diagnosis of childhood TB. In the present cross-sectional study, subjects were included using consecutive sampling method. All the children aged 0-14 years Suspected of pulmonary or extra pulmonary TB suffering from cough more than two weeks, fever without clear aetiology, loss of body weight or poor weight gain, fatigue, malaise, chronic lymph node enlargement, spine angulation, joint swelling and had history of contact with positive sputum smear adult TB patient were enrolled in the study. Pulmonary and extra pulmonary diagnosis was based on clinical presentation, Tuberculin Skin Test (TST), chest X-ray, Acid Fast Bacillus (AFB) staining and or sputum culture. Urinary LAM level was measured by using Enzyme-Linked Immunosorbent Assay (ELISA). Cut off value and Area Under the Curve (AUC) were determined using ROC statistical analysis (SPSS 21.0). Sensitivity and specificity was measured from 2x2 cross table. Out of 61 subjects suspected as TB, 49 (80.3%) were eventually diagnosed with TB. Of those diagnosed with TB, 21 (42.9%) were microbiologically confirmed cases either by sputum microscopy (34.7%) or culture (8.2%), whereas 28 subjects were unconfirmed cases (57.1%). The urinary LAM level was higher in subjects with TB (1.80+1.02) mg/l compared to non-TB group (0.46+0.3) mg/l; p<0.001(independent t-test). Urine LAM had 83% sensitivity and 85% specificity with cut off value 0.98 mg/l using microbiological and clinical confirmation as standard reference and 33% sensitivity and 60% specificity with cut off value 1.69 mg/l using microbiological confirmation only. Urinary LAM has good diagnostic value for childhood TB diagnosis.

Clofazimine for Treatment of Mycobacterium abscessus Infections in Children

Background Mycobacterium abscessus infections are increasingly common and can be challenging to treat due to antimicrobial resistance. Clofazimine (CFZ), which is commonly used for treatment of leprosy, comes as a 50 mg capsule that must be swallowed whole. It has excellent in vitro activity against M. abscessus but there are limited reports of its use, particularly in children. During a healthcare associated outbreak of M. abscessus odontogenic infections, 27 children were treated with a CFZ containing regimen for several months.MethodsData was collected on all children who received CFZ for a proven or probable M. abscessus odontogenic infection via a Food and Drug Administration Investigational New Drug Application. Demographic, diagnostic and therapeutic information was evaluated, as were laboratory results, adverse events and clinical outcomes.ResultsOf 27 children who received CFZ, 13 were male, 22 were Hispanic and mean age at initial dosing was 5.8 years (range 3.0 – 9.4 years). Patients also received azithromycin, amikacin and either imipenem or cefoxitin, though the β-lactam was stopped an average of 31 days after CFZ started. All 27 children had osteomyelitis of the jaw and received aggressive surgical debridement; 10 had a positive stain for acid-fast bacilli (AFB) and 14 had a positive AFB culture (13 M. abscessus, 1 M. chelonae). Lung nodules were present in 16 children and granulomatous lymphadenitis requiring surgery in 10. Patients received a mean of 105.6 total days of CFZ therapy (range 84–164 days) with a mean weekly dose of 7.6 mg/kg and with dosing occurring a mean of 3 days a week. Every child was able to swallow the CFZ capsule. Minor skin discoloration was noted in 6 children, dry skin in 17, and gastrointestinal symptoms in 11. No child had a clinically significant change in corrected QT interval. All children showed evidence of jaw healing and resolution of lymphadenitis at the end of therapy, and 14 had resolved or improving lung nodules.ConclusionThis is the largest reported case series of children receiving clofazimine for reasons other than leprosy. It is also the largest report of clofazimine use for extra pulmonary M. abscessus infections. Clofazimine appears to be safe in children and may be an effective part of a surgical and multi-drug regimen for M. abscessus infections.Disclosures All authors: No reported disclosures.

Common bacterial isolates, clinical outcome and TB meningitis in children admitted at Morogoro Regional Referral Hospital, Tanzania.

Bacterial meningitis is still one of the major causes of deaths, disabilities, and mental retardation in children in Morogoro region. To study the current meningitis burden, we evaluated the common bacterial isolates and clinical outcome of the disease in the region. We conducted a hospital-based prospective study on 1352 children aged between 7 days and 12 years admitted in pediatric wards at Morogoro Regional Referral Hospital for 7 months. Cerebrospinal fluid (CSF) for laboratory microbiological examination was collected by lumbar puncture in 72 children with signs and symptoms of meningitis. Latex agglutination test was used to confirm the bacterial colonies in the culture. Chi-square test was used for relative risk with 95% confidence intervals; statistical analysis and tests were considered statistically significant when P < 0.05. Among 72 CSF samples, 23 (31.9%) were positive for Streptococcus pneumoniae, 6 (8.3%) for Haemophilus influenzae, 5 (6.9%) for Group B Streptococcus, 3 (4.2%) for Escherichia coli, and 1 (1.4%) was positive for Mycobacterium tuberculosis. Furthermore, 34 CSF samples showed no bacteria growth in the culture media. In addition, 39 children (54.2%) did not respond to the treatment, whereas 79.5% (n = 39) of them died, while 20.5% (n = 39) of them were referred to a tertiary hospital. Nevertheless, the incidence of meningitis infection was 5.3% (n = 1352) among the admitted children. S. pneumoniae was the major laboratory-confirmed bacterial isolate associated with meningitis in children. We report for the first time the presence of tuberculous meningitis in Morogoro region. Ziehl-Neelsen staining for acid-fast bacilli should be mandatory for any case clinically suspected for meningitis.

Neopterin and oxidative stress markers in the diagnosis of extrapulmonary tuberculosis

Background: Extrapulmonary tuberculosis (EPTB) often presents with nonspecific signs and symptoms. Further the paucibacillary nature of extrapulmonary specimens and irregular distribution of bacilli lower the sensitivity of conventional diagnostic methods making EPTB, a diagnostic dilemma.Objective: To study neopterin, protein carbonyl and malondialdehyde (MDA) in EPTB.Methods: Sixty nine clinically confirmed cases with an equal number of age and sex matched healthy controls were enrolled. Ziehl–Neelsen staining for acid fast bacilli and culture on Lowenstein–Jensen medium were performed on all the extrapulmonary specimens. Serum neopterin and protein carbonyl levels were estimated using commercial ELISA kits. Malondialdehyde was determined by measuring thiobarbituric acid reactive substances.Results: Serum neopterin, protein carbonyl and MDA levels were significantly discriminative for cases of EPTB from healthy controls (p < 0.05). Levels of all the three biomarkers under study significantly differed between culture as well as smear positive and negative cases. A positive correlation between neopterin and protein carbonyl was seen among the cases.Conclusions: So far few studies have integrated combination of validated host biomarkers for active disease in EPTB. Our study suggests the potential diagnostic role of neopterin, protein carbonyl and MDA in EPTB.

Diagnosis of mediastinal tuberculosis: two clinical cases of patients coming from Pakistan

Tuberculosis (TB) is a common disease in Pakistan with 18 % of extra-pulmonary cases. Pakistan ranks fourth amongst high burden countries for TB in the world. Mediastinal involvement is rare in particular in the forms of lymphadenitis without lung damaging. The typology of the migration flows has modified the tuberculosis’ epidemiological distribution and the number of the extrapulmonary cases are increasing in Europe and in Italy. Diagnosis of mediastinal tuberculosis is difficult as the clinical presentation lacks specificity, imaging studies do not provide conclusive information and the differential diagnosis is a common challenge in clinical practice. The suspect of tuberculosis must be considered including acid-fast bacilli (AFB) staining (Ziehl-Nielsen and auramine), cultures and nucleic acid technology methods. We report two cases of mediastinal tuberculosis without a pulmonary tuberculosis in immunocompetent patients. This last condition, makes our cases even more rare. The first case is a man of 48-years-old presented with syncope, arrhythmia and weight loss of 20 kg during the last four months. The second case is a man of 29-years-old presented with fever (102 °F), dry cough and nocturnal sweating. The process that lead to the diagnosis of mediastinal tuberculosis, particularly in immunocompetent patients and without a concurrent diagnosis of pulmonary tuberculosis, is difficult to implement in a general clinical practice. These cases require a close examination of the differential diagnosis and the different and complex clinical pictures related to Mycobacterium tuberculosis must not be excluded. Moreover, it is needed to adopt and coordinate both mini-invasive diagnostic systems (e.g. Endobronchial ultrasound-guided transbronchial needle aspiration, EBUS-TBNA) and mycobacterial tests (microscopy, cultures and nucleic acid amplification techniques, NAAT) able to confirm or exclude the diagnosis of tuberculosis with an acceptable precision. Our cases demonstrated the key role of mycobacterial cultures in the diagnosis of these rare forms of mediastinal tuberculosis.

Causative Organisms and Outcome in Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND: Chronic obstructive pulmonary disease and its exacerbations are a major disease problem in Malabar area of Kerala associated with significant morbidity and mortality. AIMS AND OBJECTIVES: 1) To identify the causative organisms responsible for the infective exacerbations of chronic obstructive pulmonary disease. 2) To assess the clinical response to antimicrobial therapy based on sputum culture and sensitivity report. 3)To assess the influence of comorbid conditions in the outcome of chronic obstructive pulmonary disease MATERIALS AND METHODS: A hospital based, non interventional, prospective, study was conducted in the department of respiratory medicine, Pariyaram Medical College, Pariyaram, Kannur, Kerala, India. Study population was 100 consecutive adult COPD patients of either sex. Early morning sputum samples were collected in a sterile container and sent to microbiology department for Gram staining, Culture and sensitivity and acid fast bacilli staining. RESULTS: Among the total 100 patients studied most common age group was 60-69 years (42%).The mean age of study population was 65.6yrs.In this study, males constituted 97% and the rest of them were females. Sputum culture and sensitivity yielded bacterial growth in 67% of study sample.8% patients with fungal growth.25% yielded no growth. Out of 67% of study sample, 29 were streptococcus pneumoniae, which was the most common organism.15 were Hemophilus influenza, 6 were Moraxella catarrhalis and 6 were Klebsiella pneumonia. CONCLUSION: In this study, most of the acute exacerbations of COPD were caused by bacterial infections. The most common organisms isolated were streptococcus pneumoniae.

Low Transmissibility of Mycobacterium tuberculosis Based on Time to Detection From Patients With an Initial Sputum Positive by Liquid Culture but Negative by Nucleic Acid Amplification Testing and Acid-Fast Bacilli Stain

Low Transmissibility of Mycobacterium tuberculosis Based on Time to Detection From Patients With an Initial Sputum Positive by Liquid Culture but Negative by Nucleic Acid Amplification Testing and Acid-Fast Bacilli Stain

Characteristics of tuberculosis contact of children with pulmonary tuberculosis

Background Children with tuberculosis (TB) are oftenasymptomatic, so that if TB is diagnosed in a child, an adult contactshould be looked for. We realize the importance of TB control bybreaking the chain of transmission, so identification of contact andprompt treatment should be made.Objective To trace contact of children with pulmonary tuberculosis(PTB) and to determine the environmental characteristicsassociated with TB transmission.Methods Prospective, community based descriptive study wasdone in 80 children with newly diagnosed PTB treated atPediatric Pulmonary Ward, Kariadi Hospital, from September2003 to February 2004. Clinical condition, chest x-ray (CXR),acid fast bacilli (AFB) staining of sputum, and environmentalcharacteristics of adults suspected as TB contact wereexamined. Data were analyzed by uni- and bivariate analysisusing SPSS 11.5.Results Eighty adults with suspected TB were enrolled, 90% werehousehold contacts. There were 63 (79%) confirmed TB contactsin rural and urban area. Fathers were predominates (32%)followed by grandparents (26.3%), relatives (18.7%), and mothers(12.5%). There was no significant difference about internal(household) and external (non-household) family contactsbetween rural and urban area (P=1.000). In urban area, hometransmission is more frequent than rural area (P=0.340). In urbanarea, the contacts had a better perception but had no betterattitude toward treatment, although the difference was notsignificant. Behavior was worsen in rural area (P=0.214). Poorbehavior seldom occurred in those who had enough knowledgeof TB, although the difference was not statistically significant(P=0.352). In the urban area, the house of contacts had lowersleeping density (P=0.282), poor ventilation (P=0.306), and higherroom temperature (P=0.683). There were no differences in thelight intensity and humidity.Conclusion There were 79% confirmed TB contacts in rural andurban area with male predominant. There was no significantdifference between household and non-household contacts inrural and urban area. There are different characteristics, such asknowledge, perception, attitude towards treatment, and behaviorassociated with TB transmission between contacts in the ruraland urban area, and between lower, middle, and higher socio-economic level, although the difference is not significant